MASSACHUSETTS EYE AND EAR Quality and Outcomes 2014 243 Charles Street Boston, MA 02114-3096 617-523-7900 617-523-5498 (T.D.D.) MassEyeAndEar.org
M A S S A C H U S E T T S E Y E A N D E A R
Quality and Outcomes 2014
243 Charles Street
Boston, MA 02114-3096
617-523-7900
617-523-5498 (T.D.D.)
MassEyeAndEar.org
Contributors
Olumuyiwa Adebona
Shakhsanam Aliyeva
John Anderson
Christopher Andreoli
Olamide Awosanya
Sandra Baptista-Pires
Linda Belkner
Jean Bibeau
Sheila Borboli-Gerogiannis
Stacey Brauner
Charlene Callahan
Dean Cestari
Kenneth Chang
Peggy Chang
Wendy Chao
Yewlin Chee
Sherleen Chen
Teresa Chen
James Chodosh
Janet Cohan
Louise Collins
Lisa Cowan
Laura D’Amico
Linda Dagi
Reza Dana
Mindy Davis
Suzanne Day
Sandy DeCelle
Peter Delisle
Daniel Deschler
Gillian Diercks
April Dobbs
Claes Dohlman
Anne Marie Donnelly
Dean Eliott
Tobias Elze
Kevin Emerick
Kimberly Farwell
Tanya Fedyshyn
John Fernandez
Cherie Florio
Ramon Franco
Martha Fraser
Suzanne Freitag
Sandra Gallagher
Matthew Gardiner
Amanda Goggin
Evangelos Gragoudas
Stacey Gray
Scott Greenstein
Tessa Hadlock
Christopher Halpin
Christopher Hartnick
Eric Holbrook
David Hunter
Mary-Lou Jackson
Maryann Jerrier
Grace Jonak
Justin Kanoff
Dipti Karmani
Melanie Kazlas
Ivana Kim
Leo Kim
Carolyn Kloek
Elliott Kozin
Sharon Kujawa
Anne Marie Lane
Mary Leach
Daniel Lee
Daniel Lefebvre
Kathleen Lennon
Patricia Li
Derrick Lin
Robin Lindsay
Ann-Marie Lobo
John Loewenstein
Katie Luo
Joe Marshall
Maureen Martinez
Kathy McCormack
Fran McDonald
Michael McKenna
Lisa McLellan
Ralph Metson
Joan Miller
John Miller
Alfred Minincleri
Nicolas Moretti
Anne Murphy
Garyfallia Pagonis
George Papaliodis
Louis Pasquale
Eric Pierce
Roberto Pineda
Corinne Powers
Suzette Profio
Andrew Rabkin
Gregory Randolph
Nikhila Raol
Steven Rauch
Michael Reinhart
Aaron Remenschneider
Mike Ricci
Debbie Rich
Joseph Rizzo
Debra Rogers
Barbara Scully
Alexandra Selivanova
Jennifer Street
Debra Trocchi
Angela Turalba
Joseph Vadakekalam
Peter Veldman
Rhonda Walcott-Harris
Suzanne Ward
Rachel Wasserstrom
Amy Watts
Bradley Welling
Julia Wong
Janet Yedziniak
Lucy Young
Medical Illustrations by:
Laurel Cook Lhowe
Graphic Design by:
Marc Harpin,
Rhumba Design
Members of the Mass. Eye
and Ear Quality Steering
Committee also include:
Linda Belkner, R.N.
Director, Quality and
Patient Safety
Mary Kennedy
Risk Manager
Michael Ricci
Chief Information Officer
Clinical Leadership in Quality: 2014
Sunil Eappen, M.D.Assistant Professor of Anaesthesia, Harvard Medical SchoolChief Medical Officer, Chief of Anesthesiology, Massachusetts Eye and Ear
Joan W. Miller, M.D.Henry Willard Williams Professor and Chair of Ophthalmology, Harvard Medical SchoolChief of Ophthalmology, Massachusetts Eye and Ear, Massachusetts General Hospital
D. Bradley Welling, M.D., Ph.D.Walter Augustus LeCompte Professor and Chair of Otology and Laryngology, Harvard Medical SchoolChief of Otolaryngology, Massachusetts Eye and Ear, Massachusetts General Hospital
Hugh Curtin, M.D.Professor of Radiology, Harvard Medical SchoolChief of Radiology, Massachusetts Eye and Ear
Teresa C. Chen, M.D.Associate Professor of Ophthalmology, Harvard Medical SchoolChief Quality Officer, Department of Ophthalmology, Massachusetts Eye and Ear
Christopher J. Hartnick, M.D., M.S.Professor of Otology and Laryngology, Harvard Medical SchoolVice Chair of Safety and Quality/Clinical Research, Department of Otolaryngology, Massachusetts Eye and Ear InfirmaryDirector, Division of Pediatric Otolaryngology, Massachusetts Eye and Ear
Eileen Lowell, R.N., M.M.Vice President of Patient Care Services, Chief Nursing Officer, Massachusetts Eye and Ear
Please note that information
contained in this book focuses
primarily on the work of
the full-time staff at Mass. Eye
and Ear’s main Boston campus,
unless otherwise stated.
A Letter from the President
Dear Colleagues in Healthcare,
We are proud to present the 2014 Quality and Outcomes
Report of Massachusetts Eye and Ear. This annual report
showcases the results that are achieved by an outstanding
group of surgeons, nurses and staff who continually strive
for the best outcomes for all of our patients. These individuals work hard to ensure
each patient has the best experience possible while under our care, as well as
resulting quality of life.
We thank the Department Chiefs at Mass. Eye and Ear — Drs. Hugh Curtin,
Sunny Eappen, Joan Miller and Brad Welling — who enable us to achieve the
success reflected in the information you’ll see here. We continually evolve to
serve our patient population better, which is made up largely of people seen on
an outpatient basis. We have only 41 inpatient beds, but serve almost 27,000
surgical patients in a year. Many of the benchmarks of care in the field are being
set here at Mass. Eye and Ear, but we’re never satisfied with what we’ve achieved
and always work to improve our results. By publishing this report each year,
we can quantify and show what is being accomplished, so we can continue to
improve those outcomes.
In this report you’ll find information about our attention to patient safety,
and learn about how we use collaboration, advances in technology, and clinical
research to improve patient treatments and the results we achieve. The report
provides an avenue for transparency and accountability, which we feel is very
important. We hope to set the standard for outcomes achieved, and to be able
to document our continuing improvement through the information included in
these pages.
We also wish to thank the members of the quality team and the physicians,
nurses and other staff who work so hard to provide the highest quality care
each day.
We hope you find this publication interesting and useful. We welcome
your comments and feedback. For an electronic version of this report and to see
new innovations from Mass. Eye and Ear, please visit MassEyeAndEar.org/Quality.
John Fernandez
President & CEO
1
Clinical Locations
Boston — Main Campus
Boston — Longwood
Boston — Joslin
Braintree
Concord
Duxbury
East Bridgewater
Medford
Milton
Newton
Plainville
Providence
Quincy
Stoneham — Montvale Avenue
Stoneham — Woodland Road
Waltham
Weymouth
For more information, visit
MassEyeAndEar.org/Locations
About Massachusetts Eye and Ear
2
Founded in 1824, Massachusetts Eye and Ear is a pre-eminent specialty,
teaching and research hospital dedicated to caring for disorders of the eyes,
ears, nose, throat, head and neck. Our dedicated staff provides primary and
subspecialty care and serves as a referral center for inpatient and outpatient
medical and surgical care.
Mass. Eye and Ear is the leading authority in its specialties throughout the
northeast and is a resource globally for advances in patient care, research
and education. As the primary academic center for Harvard Medical School’s
Departments of Ophthalmology and Otology and Laryngology, we are deeply
committed to providing a superb education to the next generation of visionary
healthcare leaders. Our world-renowned experts are continuously innovating
in the fields of translational and bench research, turning insights into cures that
benefit countless people. We continue to forge new partnerships and alliances —
locally, nationally and beyond our borders — to increase our reach and make our
expertise, services and resources available to all who need them.
Pivotal to our clinical quality efforts is the use of the Longitudinal Medical Record
(LMR), an integrated and secure system of communication and medical record sharing
among the majority of Harvard Medical School’s network of hospitals and affiliates.
This network facilitates quick and easy communication among referring physicians
and Mass. Eye and Ear’s consulting ophthalmologists, otolaryngologists and
radiologists. It also enables our physicians to instantly tap our in-house specialists,
affording seamless and rapid access to some of the best ophthalmology and
otolaryngology resources available.
2013 Hospital Statistics
(Jan. 1 – Dec. 31, 2013)
Patient Volume
Outpatient services .............................................................................................388,551
Ambulatory surgery services and laser .................................................5,242
Inpatient surgical services ...................................................................................1,116
Emergency Department services .............................................................18,547
Discharges ............................................................................................................................1,439
Beds ......................................................................................................................................................41
Overall Operating Revenue ..................................................... $369,216,877
Massachusetts Eye and Ear
S U R G E R Y O V E R V I E W
3
The volume of surgery at Mass. Eye and Ear continued to grow
significantly this year with the opening of the Longwood operating rooms.
We continue to be the only hospital in the region to publicly report quality
outcomes data. This is our 4th consecutive year of reporting.
Mass. Eye and Ear has 21
operating rooms between the
Main Operating Room and the
6th floor Surgical Suites at the
main campus and 4 operating
rooms at the Longwood Site
on Huntington Avenue.
Currently we only care for
adult ambulatory patients at
MEE-Longwood, but we expect
to have initiated pediatric care
in January 2015 and anticipate
offering otolaryngology and
audiology services in the
summer of 2015. Regardless
of where surgery is performed,
the same measures of quality
and care are applied across
all locations. Overall volume
has grown annually for the
past 5 years.
The ophthalmology and
otolaryngology surgical
volumes have been split fairly
evenly over the past 5 years.
This year’s difference was
spurred on by the growth of
ophthalmology volume at the
Longwood Site.
4
Mass. Eye and Ear Surgical Volume
Ophthalmology and Otolaryngology Surgical Volume
Longwood 6th Floor Surgical Suite Main Operating Room Total
Ophthalmology Otolaryngology
20,000
15,000
10,000
5,000
0
12,000
10,000
8,000
6,000
4,000
2,000
0
2008 2009
2008
2010
2009
2011 2012 2013
2010 2011 2012 2013
Num
ber
of o
pera
ting
roo
m p
roce
dure
sN
umbe
r of
ope
rati
ng r
oom
pro
cedu
res
Mass. Eye and Ear cares for the
most pediatric otolaryngologic
patients in the area and for
more pediatric surgical patients
than anyone other than Boston
Children’s Hospital. Pediatric
surgical volume has remained
approximately one-third of
Mass. Eye and Ear’s overall
volume for the last few years.
Nausea is one of the most
common and troublesome
complications occurring after
surgery for both pediatric and
adult patients. Additionally,
it is well known that patients
undergoing both ophthalmologic
and otolaryngologic procedures
are at significantly higher risk
of postoperative nausea and
vomiting (PONV) when compared
to patients having other types
of surgery. As a result, nearly
every one of our patients receives
prophylactic treatment with the
latest combination of appropriate
antiemetic medications in order
to minimize the chances of
PONV.
5
Adult and Pediatric Volume
Adult Pediatric
Adult Pediatric
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
02008 2009 2010 2011 2012 2013
Num
ber
of o
pera
ting
roo
m p
roce
dure
s
Postoperative Nausea and Vomiting (PONV) in the Post Anesthesia Care Unit (PACU)
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0PONV in
PACUDelay indischarge
Perc
enta
ge
These numbers reflect patients who had nausea and/or vomiting in the Post Anesthesia Care Unit (PACU) despite therapy in the operating room and required additional treatment to treat their discomfort. The delay in discharge criteria reported reflects the number of patients who continued to have prolonged nausea despite additional therapy. Typical reports of PONV range from 20-30% incidence. Our numbers continue to exceed all published benchmarks for PONV for ambulatory surgery patients. This is a reflection of the state of the art techniques and medications utilized, as well as the close collaboration between the nurses, anesthesiologists and surgeons in caring for these patients. The data reflects a sample subset of our total patient population from 2013 who went through the recovery room (N=6,138 for adults and N=3,042 for pediatric patients).
Pain after surgery is one of
patients’ most common fears
and one of the most common
complaints after surgery. Our
goal is to have patients awaken
in the operating room and arrive
in the Post Anesthesia Care
Unit (PACU) or recovery room
as comfortable as possible.
Often, in the recovery room,
the patient may need more
analgesics prior to leaving.
Our goal is to ensure that every
patient leaves this area feeling
comfortable, whether going
home or to their hospital room.
We use a 10-point visual
analog score for adults to self-
report their pain. The scores
reported here reflect the adults’
perception of their own pain
assessment and their request
for pain medications.
For pediatric patients
old enough to assess their
own scores, we use the
same 10-point scale as used
for adults. For patients too
young to use the scale, the
nurses in the PACU use the
FLACC (Facial-Legs-Arms-
Crying-Comfortable) scale
that attributes behavioral
characteristics to a 10-point
pain scale. These are the scores
reported above for pediatric
patients.
6
Treatment Success of Pain in the PACU
Adult Pediatric
100
80
60
40
20
0Pain
treatedPain score < 3on discharge
Using 0-10 scales, our goal is to treat pain above a score of 3 and discharge patients from the PACU with scores less than 3. We report a sample subset of patients from 2013 (N=6,138 for adults and N=3,398 for pediatric patients.)
Perc
enta
ge
Massachusetts Eye and Ear
O P H T H A L M O L O G Y D E P A R T M E N T
7
At the Mass. Eye and Ear/Harvard Medical School Department of
Ophthalmology, we have nearly two centuries of experience in
developing innovative approaches to treating eye disease and reducing
blindness worldwide. We founded subspecialty training in the areas of
cornea, retina and glaucoma, and have pioneered tools and treatments
for numerous diseases and conditions ranging from retinal detachment
to age-related macular degeneration to corneal scarring. Our patient-
centered core values focus on delivering the highest quality of care
through education, innovation and service excellence.
Academic Affiliations
Harvard Medical School
Massachusetts General Hospital
Brigham and Women’s Hospital
Joslin Diabetes Center/ Beetham Eye Institute
Boston Children’s Hospital
Beth Israel Deaconess Medical Center
Veterans Affairs Boston Healthcare System
Veterans Affairs Maine Healthcare System
Cambridge Health Alliance
Aravind Eye Hospital, India
Eye and ENT Hospital of Fudan University, Shanghai, China
We Are:
• The primary teaching hospital of the Harvard Medical School Department of
Ophthalmology
• Home to Schepens Eye Research Institute, Howe Laboratory, and Berman-Gund
Laboratory for the Study of Retinal Degenerations
• Accelerating research and discovery through our multidisciplinary institutes and
subspecialty-based centers of excellence:
Institutes:
Ocular Genomics Institute
Ocular Regenerative Medicine Institute
Infectious Disease Institute
Centers of Excellence:
Age-related Macular Degeneration
Cornea
Diabetic Eye Disease
Glaucoma
Mobility Enhancement & Vision Rehabilitation
Ocular Oncology
Clinical Affiliations
• Massachusetts General Hospital (MGH) Department of Ophthalmology
- Mass. Eye and Ear provides comprehensive and subspecialty care and
inpatient consultations to MGH patients, including 24/7 emergency eye care
and trauma coverage. Mass. Eye and Ear clinicians also coordinate Neuro-
Ophthalmology and Burn Unit consultations at MGH.
- Mass. Eye and Ear staff screen MGH patients with or at high risk for diabetic
eye disease on a same-day basis in the main campus Retina Service and
through MGH’s Chelsea HealthCare Center teleretinal screening program.
- Mass. Eye and Ear’s new Same Day Service evaluates urgent and emergent
eye concerns of MGH patients as a less costly, more efficient alternative to
Emergency Department care.
• Joslin Diabetes Center/Beetham Eye Institute (BEI)
- Mass. Eye and Ear and BEI clinicians provide coordinated, integrated and
comprehensive care to patients throughout the region to prevent, diagnose
and treat patients with or at risk for diabetic eye disease.
8
Department of OphthalmologyMassachusetts Eye and Ear, Harvard Medical School
For more information about
the Mass. Eye and Ear Quality
Program or the Department
of Ophthalmology, please
visit our website at
www.MassEyeAndEar.org.
• Brigham and Women’s Hospital (BWH)
- Mass. Eye and Ear provides comprehensive and subspecialty care and
inpatient consultations to BWH patients, including 24/7 emergency eye care
and trauma coverage.
- BWH patients may also receive a full range of ophthalmic care (including
Same Day Service urgent consultation and evaluations) at Mass. Eye and
Ear, Longwood, which is staffed by Mass. Eye and Ear clinicians with
participation from Joslin diabetes specialists.
• Children’s Hospital Ophthalmology Foundation
- Mass. Eye and Ear ophthalmologists provide subspecialty care in glaucoma
and cornea disease at Boston Children’s Hospital.
- Children’s Hospital clinicians staff the comprehensive Pediatric
Ophthalmology and Strabismus Service at Mass. Eye and Ear.
Ophthalmology Resources at Mass. Eye and Ear
• Highly skilled teams provide a full spectrum of primary and subspecialty
ophthalmic care.
• Our dedicated Eye Emergency Department is available 24/7.
• The Morse Laser Center provides advanced laser procedures using state-of-the-
art refractive, glaucoma, retinal and anterior segment lasers.
• The Ocular Surface Imaging Center enables rapid, non-invasive corneal biopsies.
• Our Electroretinography Service performs evaluations of patients referred for diagnosis,
prognosis, genetic counseling and treatment of retinal degenerative disorders.
• The David Glendenning Cogan Laboratory of Ophthalmic Pathology provides
enhanced diagnostic services in conjunction with the MGH Surgical Pathology Service.
• Our expanding Optometry Service provides screening and vision care in the
context of ophthalmic practice.
• The full service Contact Lens Service specializes in therapeutic fits, bandage and
specialty contact lenses.
• The Howe Library houses one of the most extensive ophthalmology research
collections in the world.
• The Medical Unit is staffed by Mass. Eye and Ear hospitalists and nurse practitioners.
• The Radiology Department houses a dedicated MRI/CT imaging suite.
• Our dedicated Social Work and Discharge Planning Department provides
information, counseling and referral services to patients and their families.
• The International Program assists patients with appointments, transportation,
accommodations and language translation.
• The Retina Service houses a dedicated ophthalmic ultrasound imaging suite.
9
cornea
lens
pupil
iris
sclera retina
macula
optic nerve
vitreous
Data reported for 2010,
2011, 2012, and 2013
represent calendar years.
The 2009 data represent
12-month results as noted.
This bar graph shows the
number of ophthalmology
patients seen monthly by the
Mass. Eye and Ear Emergency
Department during the past
five calendar years. Throughout
this time, the Emergency
Department maintained a
high volume of ophthalmic
emergency visits, with an
average of 1,060 patients per
month in 2009, 1,050 in 2010,
1,091 in 2011, 1,304 in 2012
and 1,266 in 2013. Patient
volume generally increases
in the summer.
10
Eye Anatomy
Emergency Department: Ophthalmology Emergency Visits
1,800
1,500
1,200
900
600
300
0Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Num
ber
of v
isit
s
2009 (N = 12,717) 2010 (N = 12,603) 2011 (N = 13,086) 2012 (N = 15,650) 2013 (N = 15,189)
Month
For the past five years, the
average ophthalmology visit
time in the Mass. Eye and Ear
Emergency Department was
better than the average national
and state visit times.
The Mass. Eye and Ear
Emergency Department
has a lower LWBS rate
when compared to
national benchmarks.
11
Emergency Department: Ophthalmology Visit Times
Emergency Department: Ophthalmology “Left Without Being Seen” (LWBS) Rate
10
9
8
7
6
5
4
3
2
1
0
The Mass. Eye and Ear Emergency Department reported a “left without being seen” (LWBS) rate of 1.1% (170/15,189) of patients for all ophthalmic emergency visits in 2013; unchanged from 2012. LWBS refers to those patients who present to an emergency department but leave before being seen by a physician. According to a 2009 report by the Society for Academic Emergency Medicine, the national LWBS rate is 1.7%.1 LWBS rates vary greatly between hospitals; a review of the literature suggests a national range of 1.7% to 4.4%.1-3
References: 1Pham JC et al. National study of patient, visit and hospital
characteristics associated with leaving an emergency department without
being seen: predicting LWBS. Academic Emergency Medicine 2009;
16(10): 949–955. 2Hsia RY et al. Hospital determinants of emergency
department left without being seen rates. Ann Emerg Med 2011; 58(1):
24-32.e3. 3Handel DA et al. The use of scripting at triage and its impact
on elopements. Acad Emerg Med 2010; 17(5): 495-500.
1.7% to 4.4% 1-3
Perc
enta
ge
1.1% 1.1%
2012 (N = 15,650)
2013 (N = 15,189)
National Benchmark
5
4
3
2
1
0
2.32.1
2.32.5
3.1
Massachusetts Average 4.06 Hours
Hou
rs
The average ophthalmology visit time in the Mass. Eye and Ear Emergency Department for 2013 was 3.1 hours. The visit time is defined as the total time from when the patient walked in the door at the Mass. Eye and Ear Emergency Department to when the patient walked out the door after seeing an ophthal-mologist. According to the 2010 Press Ganey Emergency Department Pulse Report, patients across the United States spent an average of four hours and seven minutes (4.12 hours) per ER visit. The Massachusetts (State) average visit time was 4.06 hours.
National Average 4.12 Hours
2009 (N = 12,717)* 2010 (N = 12,603)
2011 (N = 13,086) 2012 (N = 15,650)
2013 (N = 15,189)
*October 2008 – September 2009
The photo on the left illustrates
the right eye of a patient who
sustained a nail gun injury at a
construction site. The nail was
removed and the wound closed;
there was no retina or lens
damage. After repair, the patient
did well and recovered to
20/20 vision.
Photo courtesy of
Matthew Gardiner, M.D.
In a retrospective review of 124
pediatric open-globe injuries
managed by the Eye Trauma
Service and/or Retina Service
between February 1999 and
April 2009, analysis showed a
median visual acuity at presen-
tation of “hand motions” (N =
123), and a final best-corrected
median visual acuity of 20/40
(N = 124) at ten months median
follow-up.1
12
Eye Trauma Surgery: Postoperative Median Vision
Eye Trauma Surgery
Bes
t-C
orre
cted
Vis
ual A
cuit
y
Preoperative Vision
Postoperative Vision
2010(N = 58)
2011 (N = 59)
2012 (N = 63)
2013(N = 68)
20/70
20/100
Light Perception
CountFingers
Hand Motions
Hand Motions
20/60
20/40
During the 2013 calendar year, 118 patients had open-globe repair by the Mass. Eye and Ear Eye Trauma Service for all surgical locations. Of these 118 patients, visual acuity at presentation was recorded in 117 patients. Visual acuity was not possible in one patient due to the patient’s mental status. At the time of publication, 68 patients had five months or more of follow-up, and only these individuals were analyzed for preoperative and postoperative vision. Patients with less than five months of follow-up were excluded from the analysis. During the 2013 calendar year, the median preoperative vision was “hand motions” and the median postoperative vision at the closest follow-up visit after five months was 20/40. Visual prognosis after ocular trauma is highly dependent on the severity of the initial trauma, but these data show that patients suffering from traumatic eye rupture can regain useful vision after surgery.
Reference: 1Shah AS, Andreoli MT, Andreoli CM, Heidary G.
“Pediatric open-globe injuries: A large scale, retrospective
review.” Poster presented at the 37th Annual Meeting of
the American Association for Pediatric Ophthalmology and
Strabismus, San Diego, California, USA, March 30-April 3,
2011. Abstract available in J AAPOS 2011; 15(1), e29.
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
Count Fingers
Hand Motions
Light Perception
No Light Perception
0%0% 0% 0% 0%
Endophthalmitis rates after
eye trauma surgery performed
at Mass. Eye and Ear are the
lowest rates reported in the
country. Based on the Mass.
Eye and Ear experience and
the low percentage of cases
with endophthalmitis, we
recommend that institutions
adopt a standardized protocol
for treating open-globe
injuries and consider the
use of prophylactic systemic
antibiotics.1
13
Eye Trauma Surgery: Rates of Endophthalmitis After Open-Globe Repair
Eye Trauma Surgery: Time to Surgical Repair for Open-Globe Injuries
During calendar year 2013, 118 patients had open-globe repair by the Eye Trauma Service, and no cases of endophthalmitis were reported for any of the surgical locations. Similar results were reported for calendar years 2012, 2011, 2010, and 2009, as shown in the graph. Prior to 2009, data were collected on all open-globe injuries treated from January 2000 to July 2007. During this 7.5-year period, 675 open-globe injuries were treated at Mass. Eye and Ear. Intravenous vancomycin and ceftazidime were started on admission and stopped after 48 hours. Patients were discharged on topical antibiotics, corticosteroids, and cycloplegics. Of these 675 eyes, 558 had at least 30 days of follow-up (mean, 11 months). The overall percentage of endophthalmitis was 0.9% (or 5/558 cases).1 The standard Mass. Eye and Ear protocol for eye trauma (i.e., surgical repair by a dedicated trauma team and 48 hours of intravenous antibiotics) is associated with post-traumatic endophthalmitis in fewer than one percent of cases. A review of the literature suggests that endophthalmitis rates after open-globe repair around the world range from 2.6% to 17% and the United States National Eye Trauma Registry has reported an endophthalmitis rate of 6.9% after open-globe repair.1
Reference: 1Andreoli CM et al. Low rate of endophthalmitis in a large series of open
globe injuries. Am J Ophthalmol 2009; 147(4): 601-608.
During calendar year 2013, 118 patients suffered open-globe injuries that required urgent surgical repair by the Eye Trauma Service. Of those patients needing emergency surgery for ocular trauma, 117 (99.2%) were taken to the operating room within 24 hours of arrival at Mass. Eye and Ear or any of its surgical locations. In one case, the open-globe repair was performed within 29 hours of arrival. The delay over our internal protocol was due to operating room staff availability due to an emergent eight-hour craniotomy patient who presented first. The mean time from presentation at the Emergency Department to arrival in the operating room was 457.9 minutes, or 7.2 hours (range: 10 minutes to 29 hours). Ninety of the 118 (76.3%) patients were taken to the operating room in under 12 hours. Multiple studies suggest the benefit of repairing open-globe injuries within 12-24 hours, in particular for the prevention of endophthalmitis. In order to assure that we are able to always provide service within this timeframe, backup trauma surgeons are available to care for simultaneous injuries needing care here and at the other sites we cover.
25
20
15
10
5
0
Perc
enta
ge o
f en
doph
thal
mit
is
2.6% to 17%
2009 (N = 95)
2010 (N = 96)
2011 (N = 98)
2012 (N = 122)
2013 (N = 118)
International Benchmark
U.S. Rate 6.9%
100
80
60
40
20
0
2009 (N = 95)
2012 (N = 122)
2013 (N = 118)
Perc
enta
ge
< 12 hours < 24 hours
Time to Operating Room
66.0%
100.0%
69.7%76.3%
99.2%99.2%
The Comprehensive
Ophthalmology and Cataract
Consultation Service at
Mass. Eye and Ear provides
a full spectrum of integrated
patient care, including annual
and diabetic eye exams,
prescriptions for eyeglasses,
continued management of a
wide range of eye problems,
and subspecialty referrals for
advanced care as needed.
The most common surgery
that we perform is cataract
extraction with intraocular lens
implantation.
Similar results were reported
for calendar years 2012, 2011,
and 2010. These results are
also consistent with an earlier
12-month period between July
2008 and June 2009, when data
collection began. For the past
five years, the Comprehensive
Ophthalmology and Cataract
Consultation Service has
consistently met or exceeded
international benchmarks for
successful cataract surgery.
14
Cataract Surgery: Achieving Target Refraction (Spherical Equivalent)
During the 2013 calendar year, the Comprehensive Ophthalmology and Cataract Consultation Service performed cataract surgery on 1,719 eyes at all surgical locations. This chart depicts the results of the 1,664 eyes that had at least one month of follow-up data. Of these 1,664 eyes, 95.7% (1,593/1,664) of cataract patients achieved within one diopter of target refraction after cataract surgery.
References: 1Kugelberg M, Lundström M.
Factors related to the degree of success in
achieving target refraction in cataract surgery:
Swedish National Cataract Register study. J
Cataract and Refract Surg 2008;34(11): 1935-
1939. 2Cole Eye Institute. Outcomes 2012. 3Lum F et al. Initial two years of experience
with the AAO National Eyecare Outcomes
Network (NEON) cataract surgery database.
Ophthalmology 2000; 107:691-697. 4Simon SS
et al. Achieving target refraction after cataract
surgery. Am J Ophthalmol 2014; 121:440-444.
normal lens cataract or cloudy
lens
Cataract Surgery
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
Dioptric difference from target refraction
71% to 94%1-4
2009 (N = 974)* 2010 (N = 1,285)
2011 (N = 1,250) 2012 (N = 1,437)
2013 (N = 1,664) International Benchmark
*July 2008-June 2009
< -2 -2 to < -1 -1 to +1 > +1 to +2 > +2
The Mass. Eye and Ear
Comprehensive Ophthalmology
Service has excellent
intraoperative complication
rates compared to international
benchmarks.
15
Cataract Surgery: Intraoperative Complication Rates
Of the 1,719 cataract surgeries performed by the Comprehensive Ophthalmology and Cataract Consultation Service during the 2013 calendar year at all surgical locations, only 2.6% (44/1,719) had intraoperative complications. These results are displayed in the graph above. Similar results were reported in calendar year 2012, during which time only 2.5% (36/1,464) of cataract surgeries had intraoperative complications.
Mass. Eye and Ear 2013 Intraoperative Complication Rates:Descemet’s tear: 0.3% (4/1,719)Posterior capsule tear and/or vitreous loss: 1.6% (27/1,719) Dropped lens/retained lens fragment: 0.2% (4/1,719)Zonular dialysis: 0.5% (9/1,719)
International Benchmarks:1-5
Descemet’s tear: 0% - 0.9%Posterior capsule tear and/or vitreous loss: 0.3% - 4.4% Dropped lens/retained lens fragment: 0% - 1.7%Zonular dialysis: 0.1% - 1.2%
References: 1Greenberg PB et al. Prevalence and predictors of ocular complications associated with cataract surgery in United
States veterans. Ophthalmology 2011; 118(3): 507-514. 2Haripriya A et al. Complication rates of phacoemulsification and manual
small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg 2012; 38: 1360-1369. 3Pingree MF et al. Cataract
surgery complications in 1 year at an academic institution. J Cataract Refract Surg 1999; 25: 705-708. 4Ng DT et al. Intraoperative
complications of 1000 phacoemulsification procedures: a prospective study. J Cataract Refract Surg 1998; 24(10): 1390-1395. 5McKellar MJ, Elder MJ. The early complications of cataract surgery: is routine review of patients 1 week after cataract extraction
necessary? Ophthalmology 2001; 108(5): 930-935.
10
9
8
7
6
5
4
3
2
1
0
Perc
enta
ge o
f in
trao
pera
tive
com
plic
atio
ns
2012 (N = 1,464)
2013 (N = 1,719)
International Benchmark
Descemet’s tear PC tear and/or vitreous loss
Nuclear fragment/dropped fragment/
retained lens fragment
Zonular dialysis
0.2% 0.3%
1.7% 1.6%
0.3% 0.2% 0.2%0.5%
0% to 0.9%
0.3% to 4.4%
0% to 1.7%
0.1% to 1.2%
The Retina Service at Mass.
Eye and Ear is one of the
largest subspecialty groups
of its kind in the country. Our
clinicians are highly skilled at
diagnosing and treating a full
range of ocular conditions,
including macular degeneration,
diabetic retinopathy, retinal
detachments, ocular tumors,
intraocular infections, and
severe ocular injuries.
16
Retina Surgery: Retinal Detachment and Retinal Detachment Repair
vitreousdetachment
subretinalfluid
retinaltear
retinaldetachment
scleral buckle
Retina Surgery: Single Surgery Success Rate for Primary Rhegmatogenous Retinal Detachment
Primary rhegmatogenous retinal detachment is one of the most common retinal conditions requiring surgical repair by the Mass. Eye and Ear Retina Service. During calendar year 2013, the Retina Service performed 489 surgical procedures to repair rhegmatogenous retinal detachments at all surgical locations. Techniques used included pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle surgery. Single surgery success rate of retinal reattachment was determined for primary, uncomplicated rhegmatogenous retinal detachments of less than one month duration for 220 eyes. In those 220 eyes, 76.4% (168/220) of the retinas were successfully reattached after one surgery at three months or greater of follow-up. Similar results were reported for calendar year 2012, during which time 80% (138/173) of retinas were successfully reattached after the first surgery. The Mass. Eye and Ear Retina Service single surgery success rate is comparable to international benchmarks reported in the literature, which show single surgery success rates ranging from 59% to 95% for primary rhegmatogenous retinal detachment repair.1-5 Benchmarks were determined from a literature review of studies that reported single surgery success rates for at least two of the three surgical techniques in this analysis (i.e., pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle).
References: 1Soni C et al. Surgical management of rhegmatogenous retinal detachment:
a meta-analysis of randomized controlled trials. Ophthalmology 2013; 120: 1440-1447. 2Feltgen N et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal
detachment study (SPR study): Risk assessment of anatomical outcome. SPR study report
no. 7. Acta Ophthalmol 2013:91:28-287. 3Adelman RA et al. Strategy for the management
of uncomplicated retinal detachments: the European Vitreo-Retinal Society retinal
detachment study report 1. Ophthalmology 2013; 120: 1804-1808. 4Sodhi A et al. Recent
trends in the management of rhegmatogenous retinal detachment. Surv Ophthalmol 2008;
53(1):50-67. 5Day S et al. One-year outcomes after retinal detachment surgery among
Medicare beneficiaries. Am J Ophthalmol 2010; 150(3):338-345.
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge o
f re
tina
s at
tach
ed
59.4% to 95%1-5
2012 (N = 173)
2013 (N = 220)
International Benchmark
80.0%76.4%
With a 99.5% success rate for
primary rhegmatogenous retinal
detachment repair after one or
more surgeries, the Mass. Eye
and Ear Retina Service continues
to maintain high success rates
for this procedure. For the
past four years, the Retina
Service has consistently met
international benchmarks of
97% to 100% for successful
rhegmatogenous retinal
detachment repair.1-5
17
Retina Surgery: Final Retinal Reattachment Rate for Primary Rhegmatogenous Retinal Detachment
During calendar year 2013, the Mass. Eye and Ear Retina Service performed 489 surgical repairs to repair rhegmatogenous retinal detachments at all surgical locations. Surgical techniques included pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle surgery. This analysis includes the 284 procedures performed on 220 eyes with primary uncomplicated rhegmatogenous retinal detachments with at least three months of follow-up. Retinal reattachment was successfully achieved in 99.5% (219/220) of eyes with a primary rhegmatogenous retinal detachment during calendar year 2013. This success rate reflects eyes that had one or more surgeries, which may have included pars plana vitrectomy, scleral buckle, and pneumatic retinopexy. The smaller number of cases in calendar year 2010 may be attributable to a more stringent follow-up of having at least five months of data.
References: 1Han DP et al. Comparison of pneumatic retinopexy and scleral
buckling in the management of primary rhegmatogenous retinal detachment.
Am J Ophthalmol 1998; 126(5), 658-668. 2Avitabile T et al. A randomized
prospective study of rhegmatogenous retinal detachment cases treated with
cryopexy versus frequency-doubled Nd:YAG laser-retinopexy during episcleral
surgery. Retina 2004; 24(6), 878-882. 3Azad RV et al. Primary vitrectomy versus
conventional retinal detachment surgery in phakic rhegmatogenous retinal
detachment. Acta Ophthalmol Scand 2007; 85, 540-545. 4Sullivan PM et al.
Results of primary retinal reattachment surgery: a prospective audit. Eye 1997;
11, 869-871. 5Day S et al. One-year outcomes after retinal detachment surgery
among Medicare beneficiaries. Am J Ophthalmol 2010;150(3): 338–345.
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge o
f re
tina
s re
atta
ched
95.6%97.4% 98.4% 99.4% 99.5%
97% to 100%1-5
2009 (N = 160)* 2010 (N = 78)
2011 (N = 189) 2012 (N = 173)
2013 (N = 220)
International Benchmark
*March 2008-February 2009
Macular Hole Surgery: Single Surgery Success Rate at Three Months
During calendar year 2013, the Mass. Eye and Ear Retina Service performed 68 surgeries (including pars plana vitrectomy, membrane peel, and gas tamponade) for macular hole repair on 61 eyes at all surgical locations. The single surgery success rate for macular hole closure was determined for primary, uncomplicated macular holes of less than six months duration for a total of 33 eyes. Of the 33 eyes that underwent primary macular hole surgery in 2013, 31 eyes (93.9%) achieved surgical success with a single operation. Success was defined as any primary macular hole that remained fully closed at greater than three months after the first surgery. Similar results were reported in calendar year 2012, during which time 27 eyes (93.1%) with primary macular hole achieved surgical success with a single operation. A review of the literature suggests that single surgery success rates for macular hole surgery range from 89.8% to 93.0%.1-3
References: 1Wu D et al. Surgical outcomes of idiopathic macular hole repair with
limited postoperative positioning. Retina 2011; 31 (3), 609-611. 2Smiddy WE et al.
Internal limiting membrane peeling in macular hole surgery. American Academy of
Ophthalmology 2001; 108, 1471-1478. 3Guillaubey A et al. Comparison of face-down
and seated position after idiopathic macular hole surgery: a randomized clinical trial.
Am J Ophthalmol 2008; 146, 128-134.
89.8% to 93.0%1-3
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge o
f cl
osed
mac
ular
hol
es
93.1% 93.9%
2012 (N = 29)
2013 (N = 33)
National Benchmark
(left) Photograph of
endophthalmitis
Photo courtesy of Lucy H. Young,
M.D., Ph.D., F.A.C.S.
Acute endophthalmitis is a
rare potential complication of
intravitreal injections. Mass.
Eye and Ear has excellent
intravitreal injection infection
rates compared to international
benchmarks.
18
During the 2013 calendar year, the Mass. Eye and Ear Retina Service performed 7,458 intravitreal injections at all service locations. Of these, no cases of acute endophthalmitis after intravitreal injection were identified. In order to identify cases of acute endophthalmitis, a retrospective review was performed of all consecutive eyes that underwent intravitreal injections from January 1, 2009 to December 31, 2013. During this five-year period, 21,050 intravitreal injections were performed by the Mass. Eye and Ear Retina Service. The overall incidence rate of endophthalmitis after intravitreal injection during this five-year period was 0.01% (three out of 21,050 injections).
References: 1Bhavsar AR et al. Risk of endophthalmitis
after intravitreal drug injection when topical antibiotics
are not required. Arch Ophthalmol 2009; 127(12): 1581-
1583. 2Englander M et al. Intravitreal injections at the
Massachusetts Eye and Ear Infirmary: analysis of treatment
indications and postinjection endophthalmitis rates. Br J
Ophthalmol 2013;97(4):460-465. 3Fileta JB et al. Meta-
analysis of infectious endophthalmitis after intravitreal
injection of anti-vascular endothelial growth factor agents.
Ophthalmic Surg Lasers Imaging Retina 2014; 45:143-149.
10
9
8
7
6
5
4
3
2
1
00.00% 0.05% 0.00% 0.03% 0.00%
Perc
enta
ge o
f en
doph
thal
mit
is
0.02% to 1.9%1
Retina Surgery: Rates of Endophthalmitis After Intravitreal Injection
2009 (N = 1,989)
2010 (N = 2,190)
2011 (N = 3,319)
2012 (N = 6,094)
2013 (N = 7,458)
International Benchmark
Retina Surgery
(left) Localization of
choroidal melanoma with
transillumination. Tantalum
rings outline the tumor.
Photo courtesy of Evangelos S.
Gragoudas, M.D.
The Ophthalmic Oncology
Service at Mass. Eye and Ear,
under the direction of Evangelos
Gragoudas, M.D., is an
international referral center for
the diagnosis and treatment of
eye neoplasms.
Proton beam irradiation
was developed at Mass. Eye and
Ear in conjunction with a team
of radiotherapists from Mass.
General Hospital. In 1975, the
first proton beam irradiation
treatment was administered to a
Mass. Eye and Ear patient with
intraocular malignant melanoma.
19
Retina Surgery: Ophthalmic Oncology – Globe Perforation Rate from Surgery
Tumors located within the eye can be challenging to diagnose and treat effectively without causing damage to the eye, resulting in a loss of vision. Proton beam irradiation is one of the most effective therapies for treating intraocular tumors while minimizing visual loss from radiation complications.1 Perforation of the globe is a potential complication during tumor localization surgery. During calendar year 2013, the Ophthalmic Oncology Service at Mass. Eye and Ear performed tantalum ring surgery in preparation for proton beam irradiation on 101 eyes. Zero cases of globe perforation from surgery were reported. There were also no cases of globe perforation reported in 2012.
Reference: 1Gragoudas ES. Proton beam irradiation of uveal melanomas:
the first 30 years. The Weisenfeld Lecture. Invest Ophthalmol Vis Sci.
2006 Nov;47(11):4666-73.
10
9
8
7
6
5
4
3
2
1
00% 0%
Perc
enta
ge o
f gl
obe
perf
orat
ions
2012 (N = 99)
2013 (N = 101)
Retina Surgery:Ophthalmic Oncology
P R E S S U R E
Glaucoma Surgery: Trabeculectomy and Tube Shunt Infection Rates
The most common incisional surgeries performed by the Mass. Eye and Ear Glaucoma Consultation Service are trabeculectomy surgery and tube shunt surgeries at all surgical locations. During the 2013 calendar year, the Glaucoma Consultation Service performed a total of 307 trabeculectomy and tube shunt surgeries. These surgeries included trabeculectomy surgery (with or without previous scarring) on 152 eyes and tube shunt surgeries (primary or revision) on 155 eyes. These procedures may have been combined with other procedures, such as cataract extraction. Zero cases of endophthalmitis were reported, and similar rates have been reported since data collection began in calendar year 2010. With trabeculectomy and tube shunt infection rates, complete success is defined as a zero percent infection rate per year. A review of the literature suggests that trabeculectomy and tube shunt infection rates range from 0.12% to 8.33%.1
Reference: 1Ang GS et al. Postoperative infection in penetrating versus non-
penetrating glaucoma surgery. Br J Ophthalmol 2010; 94(12): 1571-1576.
25
20
15
10
5
00% 0% 0% 0%
Perc
enta
ge o
f in
fect
ions
0.12% to 8.33% 1
2010 (N = 245)
2011 (N = 270)
2012 (N = 323)
2013 (N = 307)
International Benchmark
Glaucoma is a group of
disorders that affect the optic
nerve, which transmits image
signals from the retina to the
brain. In glaucoma, damage to
the optic nerve results in vision
loss. The main risk factor for
glaucoma is elevated pressure
in the eye. Members of the
Mass. Eye and Ear Glaucoma
Consultation Service are trained
in the most advanced laser
and surgical procedures to
treat glaucoma. Our specialists
treat patients with all forms
and stages of glaucoma—even
those with advanced disease—
and often receive referrals of
difficult cases.
For the past four years, the
Mass. Eye and Ear Glaucoma
Consultation Service has
maintained excellent
trabeculectomy and tube shunt
infection rates compared to
international benchmarks.
20
Glaucoma Surgery
The Mass. Eye and Ear
Glaucoma Consultation
Service continues to maintain
very favorable intraoperative
complication rates compared
to international benchmarks.
21
Trabeculectomy and Glaucoma Implant Surgery: Intraoperative Complications
10
8
6
4
2
0Conjunctival
tear/buttonholeHyphema Scleral flap
traumaVitreous loss/
prolapseSuprachoroidalhemorrhage
Scleral perforation
Of the 217 cases of trabeculectomy surgery or glaucoma implant surgery performed by the Glaucoma Consultation Service during the 2013 calendar year at all surgical locations, 98.6% (214/217) of patients had no intraoperative complications. The cases analyzed include only those trabeculectomy or implant surgeries not combined with cataract or keratoprosthesis procedures. Similar results were reported for calendar year 2012, 2011, and 2010, during which time 97.2% (314/323), 99.6% (269/270) and 95.5% (234/245) of patients had no intraoperative complications, respectively. These results are also consistent with an earlier 24-month period between July 2007 and June 2009 when 97.1% (299/308) of eyes had no intraoperative complications. Mass. Eye and Ear 2013 complication rates:Conjunctival tear/buttonhole: 1.4%Hyphema: 0%Scleral flap trauma: 0%Vitreous loss (vitreous prolapse): 0%Suprachoroidal hemorrhage: 0%Scleral perforation: 0%
The 217 cases evaluated included:79 trabeculectomies without scarring14 trabeculectomies with previous scarring105 primary tube surgeries19 tube revisions
References: 1Barton K et al. The Ahmed Baerveldt Comparison Study: methodology, baseline patient characteristics, and
intraoperative complications. Ophthalmology 2011; 118(3): 435-442. 2Jampel HD et al. Perioperative complications of
trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). Am J Ophthalmol 2005; 140(1): 16-22. 3Gedde SJ
et al. Surgical complications in the Tube Versus Trabeculectomy Study during the first year of follow-up. Am J Ophthalmol 2007;
143(1): 23-31. 4Christakis PG et al. The Ahmed Versus Baerveldt Comparison Study: design, baseline patient characteristics, and
intraoperative complications. Ophthalmology 2011; 118(11): 2172-2179.
International benchmarks:1-4
Conjunctival tear/buttonhole: 1.1% - 3.0%Hyphema: 1.0% - 8.0%Scleral flap trauma: 0.7%Vitreous loss (vitreous prolapse): 1.0%Suprachoroidal hemorrhage: 0% - 1.0%Scleral perforation: 0% - 3.0%
Perc
enta
ge o
f in
trao
pera
tive
com
plic
atio
ns
2007-2009 (N = 308)* 2010 (N = 245)
2011 (N = 270) 2012 (N = 323)
2013 (N = 217) International Benchmark
*July 2007-June 2009
1.1% to 3%
1% to 8%
0.7%1% 0% to 1%
0% to 3%
Preoperative and postoperative
intraocular pressure (IOP)
measurements were taken
using the Tono-Pen (Reichert,
Buffalo, NY) prior to the laser
procedure and within one
hour of the conclusion of
the laser procedure. For this
analysis, if multiple pressure
readings were taken, the
average pressure reading was
used when calculating the
IOP difference (postoperative
minus preoperative). All
measurements were taken
by a certified ophthalmic
technician. All patients received
either brimonidine 0.1% or
0.15% or apraclonidine 0.5%
before the laser procedure and
prednisolone 1% after the
procedure.
22
Glaucoma Laser Surgery: Postoperative Intraocular Pressure (IOP) Spikes
During calendar year 2013, the Glaucoma Consultation Service performed anterior segment laser procedures on 742 eyes at all laser locations. Of the 742 eyes, this analysis includes the 587 eyes that had laser peripheral iridotomies (210), capsulotomies (65) and laser trabeculoplasties (312). Of the 312 laser trabeculoplasties, 64 were argon laser trabeculoplasties (ALT) and 248 were selective laser trabeculoplasties (SLT). Similar results were reported in calendar year 2012, when data collection began.
≥5 mm Hg ≥10 mm Hg Mass. Eye Mass. Eye and Ear International1-8 and Ear International1,3-4,6-9
Laser peripheral iridotomy: 19% 0% - 35% 5.5% 0%
Capsulotomy: 7.7% 5.7% - 13% 0% 0.02% - 4%
Laser trabeculoplasty: 11.2% 7% - 10.3% 1.9% 3%
Overall: 13.6% 0% - 31.7% 3.1% 0% - 9.8%
References: 1Chevier RL et al. Apraclonidine 0.5% versus brimonidine 0.2% for the control of intraocular pressure elevation following
anterior segment laser procedure. Ophthalmic Surg Lasers 1999; 30(1): 199-204. 2Yuen NSY et al. Comparing brimonidine 0.2% to
apraclonidine 1.0% in the prevention of intraocular pressure elevation and their pupillary effects following laser peripheral iridotomy.
Jpn J Ophthalmol 2005; 49(1): 89-92. 3Yeom HY et al. Brimonidine 0.2% versus brimonidine purite 0.15%: prophylactic effect on
IOP elevation after Nd:YAG laser posterior capsulotomy. Journal of Ocular Pharm. & Therapeutics 2006; 22(1): 176-181. 4Collum RD
Jr. et al. The effect of apraclonidine on the intraocular pressure of glaucoma patients following Nd:YAG laser posterior capsulotomy.
Ophthalmic Surgery 1993: 24(9): 623-626. 5Lai JSM et al. Five-year follow-up of selective laser trabeculoplasty in Chinese eyes. Clin
Experiment Ophthalmol 2004; 32(1): 368-372. 6Francis BA et al. Selective laser trabeculoplasty as a replacement for medical therapy
in open-angle glaucoma. Am J Ophthalmol 2005; 140:524–525. 7Chen TC et al. Brimonidine 0.2% versus apraclonidine 0.5% for
prevention of intraocular pressure elevations after anterior segment laser surgery. Ophthalmology 2001;108:1033-103. 8Chen TC.
Brimonidine 0.15% versus apraclonidine 0.5% for prevention of intraocular pressure elevation after anterior segment laser surgery. J
Cataract Refractive Surg 2005; 31(9): 1707–1712. 9Hong C et al. Effect of apraclonidine hydrochloride on acute intraocular pressure
rise after argon laser iridotomy. Korean J Ophthalmol 1991; 5(1): 37-41.
40
30
20
10
0
≥5 mm Hg ≥10 mm Hg
Perc
enta
ge o
f IO
P sp
ikes
Laser peripheral iridotomy
Laser peripheral iridotomy
Capsulotomy CapsulotomyLaserTrabeculoplasty
(ALT/SLT)
LaserTrabeculoplasty
(ALT/SLT)
Overall Overall
0% to 35%
5.7% to 13%
7% to 10.3%
0% 3%
0% to 31.7%
0% to 9.8%
0.02% to 4%
2012 (N = 556) 2013 (N = 587) International Benchmark
In summary, the Mass. Eye
and Ear Glaucoma Consultation
Service achieves excellent
surgical success with
trabeculectomy, and
reoperation rates are low.
23
Glaucoma Surgery: Mitomycin C Trabeculectomy Reoperation Rates at One Month and Six Months
10
9
8
7
6
5
4
3
2
1
0
Trabeculectomy is the gold standard incisional surgery for glaucoma patients who require surgery. There were 93 mitomycin C trabeculectomy surgeries (with or without scarring) performed by the Glaucoma Consultation Service for the 2013 calendar year at all surgical locations. Reoperation rates were calculated at the one-month and six-month postoperative time period. Reoperations were defined as glaucoma procedures required for further intraocular pressure lowering (i.e., repeat trabeculectomy, tube shunt surgery, diode cyclophotocoagulation, etc.). One patient was lost to follow-up at the six-month time period. The Mass. Eye and Ear Glaucoma Consultation Service reoperation rate for mitomycin C trabeculectomy surgery at one month was 2.2% (two patients underwent bleb revisions) and at six months was 4.3% (the aforementioned two bleb revisions, and two tube shunt surgeries). To the best of our knowledge, published data on one- and six-month reoperation rates are lacking; thus, our rates are good internal benchmarks to continue to follow.
Perc
enta
ge o
f re
oper
atio
ns
4.3%
One Month Postoperative (N = 93)
Six Months Postoperative (N = 92)
2.2%
1.
3.
2.
4.
Refractive surgery, commonly
known as laser vision
correction, is a term given
to surgical procedures
designed to correct certain
visual problems such as
myopia (nearsightedness),
hyperopia (farsightedness),
and astigmatism. The Mass.
Eye and Ear Cornea and
Refractive Surgery Service
offers a number of refractive
procedures, the most common
of which are laser-assisted
in situ keratomileusis
(LASIK) and photorefractive
keratectomy (PRK).
During the 2013 calendar
year, 248 of the 263 eyes
that had LASIK surgery had
sufficient follow-up data for
analysis. Sufficient follow-
up was defined as at least
one month of follow-up for
myopia and three months
follow-up for hyperopia.
In calendar year 2013,
the overall LASIK success
rate for achieving within 0.5
diopters of target refraction
for myopia and hyperopia
was 88.7% (220/248 eyes).
24
Refractive Surgery (Laser Vision Correction)
Refractive Surgery — LASIK for Myopia: Achieving Target Refraction (Spherical Equivalent)
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge w
ithi
n 0.
5 di
opte
rs o
f ta
rget
ref
ract
ion
During the 2013 calendar year, 212 of the 248 eyes that had LASIK surgery were myopic and had at least one month follow-up data for analysis. The LASIK success rate for myopia at one month was 90.1% (191/212 eyes) for calendar year 2013. Benchmark data from FDA trials for LASIK for myopia showed that 71.6% of eyes resulted in a refractive error within 0.5 diopters of the intended target correction.1 Further review of the literature suggests that after LASIK surgery for myopia, approximately 70% to 83% of eyes achieve within 0.5 diopters of the intended target correction.1-2 For the past five years, the Mass. Eye and Ear Cornea and Refractive Surgery Service has consistently exceeded international benchmarks for successful LASIK surgery for myopia.
References: 1Bailey MD, Zadnick K. Outcomes of LASIK for
myopia with FDA-approved lasers. Cornea 2007; 26(3),
246–254. 2Yuen LH et al. A 10-year prospective audit of LASIK
outcomes for myopia in 37,932 eyes at a single institution in
Asia. Ophthalmology 2010; 117(6): 1236–1244.
86.9% 86.9% 88.1% 89.3% 90.1%
70% to 83%1-2
2009 (N = 289)* 2010 (N = 252)
2011 (N = 260) 2012 (N = 271)
2013 (N = 212) International Benchmark
*July 2008-June 2009
The Mass. Eye and Ear Cornea
and Refractive Surgery Service
continues to maintain a high
overall success rate for LASIK
surgery for myopia.
25
Refractive Surgery — LASIK for Different Degrees of Myopia: Achieving Target Refraction (Spherical Equivalent)
In calendar year 2013, 212 of the 248 eyes had LASIK surgery for myopia, and the success rates based on the degree of myopia are graphed here. LASIK for low myopia was performed on 80 eyes, and of these, 95% (76/80 eyes) were successful. For the 116 eyes with moderate myopia, 87.9% (102/116 eyes) were successful; and for the 16 eyes with high myopia, 81.3% (13/16 eyes) achieved within 0.5 diopters of target refraction at one month follow-up. Similar results were reported for the 2012, 2011 and 2010 calendar years, during which time the success rate for low myopia was 90.4% (75/83 eyes), 97.3% (71/73 eyes) and 91.5% (86/94 eyes), respectively. Moderate myopia success rates were consistent for 2012, 2011 and 2010 with 91.2% (145/159 eyes), 82.1% (128/156 eyes) and 85.4% (105/123 eyes), respectively. Results for LASIK for high myopia ranged from 75.9% (22/29 eyes) in 2012, to 96.8% (30/31 eyes) in 2011 and 80% (28/35 eyes) in 2010. These results are also consistent with the 12-month period between July 2008 and June 2009, which had success rates for low, moderate and high myopia of 86.1% (93/108 eyes), 87.8% (145/165) and 81.3% (13/16 eyes), respectively.
100
90
80
70
60
50
40
30
20
10
0Low Myopia
less than 3 diopters of sphereModerate Myopia
3 to <7 diopters of sphereHigh Myopia
7 to 10 diopters of sphere
Perc
enta
ge w
ithi
n 0.
5 di
opte
rs o
f ta
rget
ref
ract
ion
2009 (N = 289)* 2010 (N = 252) 2011 (N = 260) 2012 (N = 271) 2013 (N = 212)
*July 2008-June 2009
86.1
91.5
97.3
90.4
95.0
87.885.4
82.1
91.287.9
81.3 80.0
96.8
75.9
81.3
26
Refractive Surgery — LASIK for Hyperopia: Achieving Target Refraction (Spherical Equivalent)
79.3%85.0%
77.8%
68.0%
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge w
ithi
n 0.
5 di
opte
rs o
f ta
rget
ref
ract
ion
Of the 51 eyes that had LASIK surgery for hyperopia during the 2013 calendar year, 36 had three months or more of follow-up data for analysis. The overall 2013 LASIK success rate for achieving within 0.5 diopters of target refraction was 80.6% (29/36 eyes) for hyperopia. A review of the literature suggests that the success rate for achieving within 0.5 diopters of the intended target correction after LASIK for hyperopia ranges between 66.7% and 91%.1-3
References: 1Alio JL et al. Laser in situ keratomileusis for high
hyperopia (>5.0 diopters) using optimized aspheric profiles:
efficacy and safety. J Cataract Refract Surg 2013; 39: 519-527. 2Keir NJ et al. Outcomes of wavefront-guided laser in situ
keratomileusis for hyperopia. J Cataract Refract Surg 2011;
37(5): 886–893. 3Cole Eye Institute. Outcomes 2012.
80.6%
66.7% to 91%1-3
2009 (N = 40)* 2010 (N = 29)
2011 (N = 25) 2012 (N = 36)
2013 (N = 36) International Benchmark
*July 2008-June 2009
Failed Graft 62.1%
For the past four years, the
Mass. Eye and Ear Cornea and
Refractive Surgery Service has
maintained low enhancement/
retreatment rates when
compared to international
benchmarks.
For the past five years, the
Mass. Eye and Ear Cornea
and Refractive Surgery Service
has consistently met the
international benchmarks
for successful LASIK surgery
for hyperopia.
Refractive Surgery — LASIK: Enhancement/Retreatment Rates at Six Months Follow-up
50
45
40
35
30
25
20
15
10
5
0
Of the 248 eyes that had LASIK surgery for myopia or hyperopia during the 2013 calendar year, 5.2% (13/248) had an enhancement/retreatment procedure within six months. Similar results have been reported since calendar year 2010, when data collection for enhancement/retreatment rates began. LASIK retreatment rates of between 3.8% and 29.4% have been reported in the literature.1-3
References: 1Bragheeth MA et al. Re-treatment after laser
in situ keratomileusis for correction of myopia and myopic
astigmatism. Br J Ophthalmol 2008; 92(11): 1506-1511. 2Yuen LH et al. A 10-year prospective audit of LASIK
outcomes for myopia in 37,932 eyes at a single institution
in Asia. Ophthalmology 2010; 117(6): 1236-1244. 3Alio JL
et al. Laser in situ keratomileusis for high hyperopia (>5.0
diopters) using optimized aspheric profiles: efficacy and
safety. J Cataract Refract Surg 2013; 39: 519-527.
3.8% to 29.4% 1-3
LASI
K r
etre
atm
ents
/enh
ance
men
ts
7.4% 6.8%5.2%
2010 (N = 296) 2011 (N = 285)
2012 (N = 307) 2013 (N = 248)
International Benchmark
2.7%
(left) Photograph of
keratoprosthesis (KPro)
Photo courtesy of
Claes Dohlman, M.D., Ph.D.
27
Cornea Surgery:Keratoprosthesis (KPro)
The Boston keratoprosthesis (KPro) is an artificial cornea developed at Mass. Eye and Ear by Claes Dohlman, M.D., Ph.D. and colleagues. Dr. Dohlman is former Chief and Chair of the Department of Ophthalmology, and currently Emeritus Professor of Ophthalmology at Harvard Medical School. In development since the 1960s, the KPro received FDA clearance in 1992 and achieved European Conformity (CE) Mark approval in June 2014. It is the most commonly used artificial cornea in the U.S. and world-wide, with more than 10,000 implantations to date. The KPro is reserved for patients blinded by corneal disease and for whom a standard corneal transplant is not a viable option.1
N = 29
Cornea Surgery:Surgical Indications for Keratoprosthesis (KPro)
Thirty-seven patients received the type 1 Boston keratoprosthesis (KPro) during calendar year 2013. Of these 37 patients, 29 (78.3%) received a KPro for the first time and are included in this analysis. Similar data were reported for calendar year 2012, during which time 36 patients received a type 1 KPro, with 25 of them having a primary type 1 KPro with at least three months of follow-up data. Indications for KPro surgery included failed corneal grafts (18/29, 62.1%), aniridic keratopathy (6/29, 20.7%), corneal neovascularization (3/29, 10.3%), mucus membrane pemphigoid (1/29, 3.4%), and perforated cornea (1/29, 3.4%). Nine patients (9/29, 31%) received the KPro as a primary procedure. Two aniridic eyes had prior failed grafts but were only graphed in the aniridic keratopathy category.
Reference: 1Ament JD et al. Cost-effectiveness
of the Boston keratoprosthesis. Am J Ophthalmol
2010; 149: 221-228.
Failed Graft 62.1%
Mucus MembranePemphigoid
3.4%
Corneal Neovascularization10.3%
Perforated Cornea3.4%
AniridicKeratopathy20.7%
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
28
Cornea Surgery:Visual Outcomes of Keratoprosthesis (KPro)
Cornea Surgery:Keratoprosthesis (KPro) Retention Rates
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
Of the 29 primary type 1 Boston keratoprosthesis (KPro) surgeries in calendar year 2013 for which three months of follow-up data were available, 100% of patients retained the KPro at three months. Similar results were reported for calendar years 2011 and 2012, during which time, 100% of patients retained the KPro at three months. According to the literature, expected retention rates range from 90.5% to 95% of patients.1-2
References: 1Kang JJ et al. Visual outcomes of Boston keratoprosthesis
implantation as the primary penetrating corneal procedure. Cornea 2012;
0(0): 1-5. 2Zerbe BL et al. Results from the multicenter Boston type I
keratoprosthesis study. Ophthalmology 2006; 113(1): 1779.e1-1779.e7.
100% 100% 100%
90.5% to 95%1-2
2011 (N = 27)
2012 (N = 25)
2013 (N = 29)
National Benchmark
2011 (N = 27)
2012 (N = 25)
2013 (N = 29)
National Benchmark
During calendar year 2013, 29 patients underwent primary type 1 Boston keratoprosthesis (KPro) surgery for the first time and had at least three months of follow-up data available for analysis. Of these 29 patients, 22 (76%) achieved 20/200 vision or better at any point within the three-month postoperative period or beyond. This is comparable to national benchmarks of 56% to 89% reported in the literature.1-3
Seven patients did not achieve a postoperative vision of 20/200 or better, and in each case, the patient had pre-existing severe retinal disease or advanced glaucoma, which limited the visual acuity. References: 1Kang JJ et al. Visual outcomes of Boston keratoprosthesis
implantation as the primary penetrating corneal procedure. Cornea 2012;
0(0): 1-5. 2Zerbe BL et al. Results from the multicenter Boston type I
keratoprosthesis study. Ophthalmology 2006; 113(1): 1779.e1-1779.e7. 3Greiner MA et al. Longer-term vision outcomes and complications with
the Boston type 1 keratoprosthesis at the University of California, Davis.
Ophthalmology 2011; 118: 1543-1550.
56% to 89%1-3
20/200or better
66.7%
84%
76%
For the past three years, the
Mass. Eye and Ear Cornea
and Refractive Surgery Service
has consistently met national
benchmarks for visual outcomes
following keratoprosthesis
(KPro) surgery.
KPro retention rates at three
months were 100% in 2011,
2012, and 2013.
(left) The photos illustrate
the before and after of an
eye that underwent
penetrating keratoplasty (PK)
for pseudomonas keratitis
in a prior radial keratotomy
incision.
Photo courtesy of
James Chodosh, M.D., M.P.H.
29
Cornea Surgery: Penetrating Keratoplasty
The proportion of
keratoplasties performed in
partial thickness fashion by
surgeons of the Mass. Eye
and Ear Cornea Service
increased from 10% in 2009
to 67% in 2013.
Cornea Surgery: Distribution of Full-Thickness and Partial-Thickness Keratoplasty
During the 2013 calendar year, the Mass. Eye and Ear Cornea Service performed 256 keratoplasty procedures at all surgical locations; of these, 134 (52.3%) were full-thickness and 122 (47.7%) were partial-thickness, or lamellar. Fifty penetrating (full-thickness) keratoplasties (PKs) were done in combination with retinal, glaucoma or KPro procedures and were excluded from the distribution analysis. Additionally, there were 23 therapeutic PKs done for active infection or non-healing ulcers and these were also excluded from the analysis. This left 61 PKs for inclusion in the distribution analysis compared to 122 partial-thickness procedures: 107 Descemet’s stripping endothelial keratoplasties (DSEK) and 15 deep anterior lamellar keratoplasties (DALK).
N = 183
Penetrating Keratoplasty (PK)33.3%
Deep AnteriorLamellar Keratoplasty(DALK)8.2%
Descemet’sStripping Endothelial Keratoplasty (DSEK)
58.5%
30
In 2013, the most common
indications for elective full-
thickness keratoplasties (PKs)
at Mass. Eye and Ear were
failed corneal graft (41.4%),
corneal scar (24.1%), and
keratoconus (15.5%).
For the past five years, the
Mass. Eye and Ear PK surgery
success rates have consistently
met or exceeded international
benchmarks.1-2
Cornea Surgery: Surgical Indications for Penetrating Keratoplasty (PK)
During the 2013 calendar year, 134 penetrating (full-thickness) keratoplasties (PKs) were performed by the Mass. Eye and Ear Cornea and Refractive Surgery Service at all surgical locations. The current analysis includes only those elective PKs for which up to three months of follow-up data were available and which were not done in combination with retinal, glaucoma or KPro procedures. This left 58 (43.3%) elective PKs for analysis for calendar year 2013. These 58 elective PKs included first-time grafts in uninflamed host beds as well as those performed in eyes at high risk of rejection, including those with extensive corneal neovascularization and/or eyes with a failed corneal graft. Indications for elective PKs included failed corneal graft (24/58, 41.4%), corneal scar (14/58, 24.1%), keratoconus (9/58, 15.5%), Fuchs’ dystrophy (4/58, 6.9%), bullous keratopathy (3/58, 5.2%), corneal edema (2/58, 3.5%), corneal dystrophy (1/58, 1.7%), and neurotrophic keratopathy (1/58, 1.7%).
N = 58
Corneal Dystrophy1.7%
NeurotrophicKeratopathy
1.7%
Corneal Edema3.5%
BullousKeratopathy5.2%
Keratoconus15.5%
Corneal Scar24.1%
Failed Corneal
Graft41.4% Fuchs’
Dystrophy6.9%
Cornea Surgery: Clear Corneal Grafts after Penetrating Keratoplasty (PK) Surgery at Three Months Follow-up
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge o
f gr
afts
cle
ar f
or e
lect
ive
PK
Fifty-eight of the 134 PKs (full-thickness) performed in 2013 at all surgical locations were elective with up to three months follow-up analysis. Of these elective PKs, 57 (98.3%) achieved surgical success, which is defined as a graft at three months follow-up with minimal (to no) clinical edema and which possesses clarity sufficient to permit the examiner to have an unencumbered view of the interior of the eye including iris details.
References: 1Vail A et al. Corneal graft survival and visual
outcome: a multicenter study. Ophthalmology 1994;
101(1):120-127. 2Price MO et al. Risk factors for various
causes of failure in initial corneal grafts. Arch Ophthalmol
2003; 121:1087-1092.
93.0% 92.8%98.3% 98.3%
92.5% to 95%1-2
96.8%
2009 (N = 126)* 2010 (N = 71)
2011 (N = 69) 2012 (N = 60)
2013 (N = 58) International Benchmark
*July 2008-July 2009
Oculoplastic Surgery: Reoperation Rate for External Dacryocystorhinostomy (Ex-DCR) Surgery at Six Months Follow-up
25
20
15
10
5
0
Reo
pera
tion
rat
e af
ter
exte
rnal
DC
R s
urge
ry (
%)
During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed external dacryocystorhinostomy (Ex-DCR) procedures on 73 eyes of 65 patients at all surgical locations. Seventeen eyes of 16 patients were excluded for pre-existing ocular conditions such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), and benign tumors. This analysis includes the remaining 56 eyes of 49 patients who underwent primary Ex-DCR in 2013 for primary acquired nasolacrimal duct obstruction (NLDO). Of these eyes, 1.8% (1/56) required a second procedure within six months in order to achieve surgical success. Similar results were reported for calendar year 2012, during which time there were no reoperations within six months of primary Ex-DCR. Ex-DCR is often considered the standard of care for NLDO. A review of the literature suggests that 7.8% - 12.5% of patients require reoperation following primary Ex-DCR for primary acquired NLDO.1-3
References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with
nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003; 110:78-84. 2Karim R et al. A comparison of external and endoscopic dacryocystorhinostomy
for acquired nasolacrimal duct obstruction. Clinical Ophthalmology 2011; 5:979-
989. 3Ben Simon GJ et al. External versus endoscopic dacryocystorhinostomy for
acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology
2005; 112:1463-1468.
7.8% to 12.5%1-3
2012 (N = 70)
2013 (N = 56)
International Benchmark
0.0%
1.8%
31
Oculoplastic Surgery: Dacryocystorhinostomy (DCR) Lacrimal Bypass Surgery
For the past two years, the
Mass. Eye and Ear Ophthalmic
Plastic Surgery Service has
maintained a low reoperation
rate for Ex-DCR surgeries
compared to international
benchmarks.
Dacryocystorhinostomy (DCR)
is a surgery that aims to
improve tear drainage from the
lacrimal sac to the nose.
Lacrimal gland
Canaliculus
Lacrimal sac
DCR ostium site
Nasolacrimal duct
2% to 11%1-4
Oculoplastic Surgery: Reoperation Rate for Lid Surgeries at Six Months Follow-up
32
In contrast to conventional
external DCR (Ex-DCR),
En-DCR is a minimally invasive
procedure that is possible due
to technological advances in
instruments of rhinologic surgery.
This analysis includes En-DCR
procedures done in patients
with underlying sinus disease or
other intranasal abnormality such
as significant septal deviation.
Approximately half of all En-DCR
procedures reported for 2013
were done in collaboration with
rhinologists from the Mass. Eye
and Ear/Harvard Medical School
Department of Otolaryngology.
The Mass. Eye and Ear
Ophthalmic Plastic Surgery
Service continues to have one
of the lowest reoperation rates
for eyelid surgeries compared
to international benchmarks.
Oculoplastic Surgery: Reoperation Rate for Endoscopic Dacryocystorhinostomy (En-DCR) Surgery at Six Months Follow-up
25
20
15
10
5
0
Reo
pera
tion
rat
e af
ter
lid s
urge
ry (
%)
During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed upper-lid blepharoplasty and/or ptosis repair surgeries on 574 eyelids in 341 patients at all surgical locations. Of these eyelids, only 3.1% (18/574) required a second procedure within six months in order to achieve surgical success. Similar results were reported for calendar years 2011 and 2012, during which time 2.6% (11/416) and 1.7% (8/467) of eyelids, respectively, required a second procedure within six months. These results are also consistent with an earlier 12-month period from March 2008 to February 2009 when 2.9% (10/343) of eyelids required a reoperation. A review of the literature suggests that reoperation rates after eyelid surgery range from 2.6% to 8.7%.1-2
References: 1Scoppettuolo E et al. British Oculoplastic Surgery
Society (BOPSS) National Ptosis Survey. Br J Ophthalmol 2008;
92(8): 1134–1138. 2Melicher J, Nerad JA. Chapter 29: Ptosis
surgery failure and reoperation. In: Cohen AJ, Weinberg DA,
eds. Evaluation and management of blepharoptosis. New York:
Springer; 2011, 269-274.
2.6% to 8.7%1-2
2009 (N = 343)* 2011 (N = 416)
2012 (N = 467) 2013 (N = 574)
International Benchmark
*March 2008-February 2009
2.9% 2.6%1.7%
3.1%
25
20
15
10
5
0
Reo
pera
tion
rat
e af
ter
endo
scop
ic D
CR
sur
gery
(%
)
During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed endoscopic dacryocystorhinostomy (En-DCR) procedures on 41 eyes of 37 patients at all surgical locations. Twenty-three eyes of 20 patients were excluded for pre-existing ocular conditions such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), and benign tumors. Procedures involving laser DCR were also excluded. This analysis includes the remaining 18 eyes of 17 patients who underwent primary En-DCR in 2013 for primary acquired nasolacrimal duct obstruction. Of these eyes, 5.6% (1/18) required a second procedure within six months to achieve surgical success. A review of the literature suggests that 2% to 11% of patients who undergo primary En-DCR for primary acquired nasolacrimal duct obstruction require a revision.1-4
References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser
endonasal dacryocystorhinostomy. Ophthalmology 2003; 110: 78-84. 2Ben Simon GJ
et al. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal
duct obstruction in a tertiary referral center. Ophthalmology 2005; 112:1463-1468. 3Moore WM et al. Functional and anatomic results after two types of endoscopic
endonasal dacryocystorhinostomy. Ophthalmology 2002; 109: 1575-1582. 4Codere F
et al. Endonasal dacryocystorhinostomy: a modified technique with preservation of the
nasal and lacrimal mucosa. Ophthal Plast Reconstr Surg 2010; 26:161-164.
5.6%
2013 (N = 18)
International Benchmark
exotropia (XT)esotropia (ET)
recession surgeryresection surgery
part of muscleresected
musclerecessed
muscleadvanced
after surgery
Recession and resection
procedures are most commonly
performed for horizontal
misalignment. Other surgeries
less frequently performed
include loop myopexies and
transpositions.
33
Pediatric and Adult Strabismus Surgery
Pediatric and Adult Strabismus Surgery: Outcomes Criteria
Strabismus surgery, the most commonly performed ophthalmic procedure in children,
is offered to adults as well. Surgery is performed for a variety of indications including
restoration of binocular vision, restitution of normal eye contact (reconstructive),
treatment of double vision, or reduction of anomalous head posture (torticollis).
Since the desired surgical outcome depends on the primary indication of surgery, we
developed a unique goal-directed methodology to assess surgical outcomes.1 This
approach provides the most clinically relevant appraisal of our outcomes. The model
excludes no patient based on diagnosis or procedure performed, and therefore facilitates
stratification based on the presence or absence of risk factors (ophthalmic or systemic)
that might impact results. The tables on the following pages summarize the criteria, and
the figures that follow illustrate our outcomes using this goal-directed methodology.
These reported pediatric and adult strabismus surgery outcomes include procedures
done at all surgical locations.
Reference: 1Ehrenberg M et al. Goal-determined metrics to assess outcomes of esotropia surgery. JAAPOS 2014;18:211-16.
Our goal-directed methodology
provides a clinically relevant
appraisal of strabismus surgery
outcomes. Reported results
were monitored two to six
months after strabismus
surgery was performed.
34
Indications for strabismus
surgery included restoration
of binocular vision, restitution
of normal eye contact
(reconstructive), treatment of
double vision, or reduction
of anomalous head posture
(torticollis).
Pediatric and Adult Strabismus Surgery:Outcomes Criteria
1. Goal—Binocular Potential for Esotropia (ET)
Subjective Distance angle1 Near angle
Excellent ET≤10∆ or XT≤5∆ No XT, any ET
Good 10∆< ET≤15∆ or X(T)≤10∆ any ET
5∆<XT ≤10∆
Poor Recommend reoperation ET>15 or XT>10
(horizontal)
1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky
∆ = prism diopter
2. Goal—Binocular Potential for Exotropia (XT)
Sensory Distance angle1 Near angle
Excellent Near stereo-acuity <2 octaves XT<10∆ XT<10∆ worsened from pre-op and or ET<6∆ or ET<6∆
not diminished to nil2
Good Near stereo-acuity <2 octaves 10∆≤XT<15∆ 10≤XT<15∆
worsened from pre-op and or 6≤ET≤10∆ or 6≤ET≤10∆
not diminished to nil2
Poor Recommend reoperation XT>_15∆ XT>_15∆
(horizontal) or ET>>10∆ or ET>>10∆
1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky 2. Accept Worth-4-dot test (W4D) fusion if stereo-acuity data not available ∆ = prism diopter
3. Goal—Reconstructive (ET or XT)
Subjective Angle1,2
Excellent3 ET or XT≤10∆
Good 10∆<ET or XT≤15∆
Poor Recommend reoperation ET or XT>15∆
(horizontal)
1. Order of preference for angle used: Krimsky > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT)
2. Near angle (unless stated goal of distance angle)3. Ignore coexisting vertical deviation
Although there were no
surgeries performed for
torticollis in calendar year
2013, there were four cases
in calendar year 2012.
35
4. Goal—Resolution of Diplopia (ET or XT)
Subjective
Excellent No diplopia in primary1
Good2,3 Diplopia controlled with prism
Poor Recommend reoperation for diplopia and/or diplopia
not comfortably controlled with prism correction
1. At distance and near but may have rare diplopia in primary, or diplopia away from primary2. Pre-existing vertical alignment controlled with prism does not affect result if no increase3. New vertical alignment requiring prism cannot exceed “good” outcome
5. Goal—Reduction of Torticollis (ET or XT)
Subjective1 Torticollis2
Excellent ≤8°
Good >8°≤12°
Poor Recommend reoperation for diplopia or torticollis >12°
1. Subjective category trumps the other categories 2. Distance (unless stated goal of near)
Pediatric and Adult Strabismus Surgery:Outcomes Criteria
36
Of the 97 patients with
exotropia, 29 patients
underwent surgery to restore
binocular vision, 60 for
reconstructive purposes, and 8
for diplopia. Exotropia patients
are grouped according to the
primary goal for surgery.
Of the 97 patients with
exotropia who underwent
strabismus surgery in 2013,
50 patients had associated
risk factors.
Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by Goal
100
80
60
40
20
0
100
80
60
40
20
0
21.4
7.1
71.4
48.3
24.1
27.6
10.3
14.1
75.683.3
3.3
13.3
100.087.5
12.5 11.5
11.5
77.073.2
9.3
17.5
Perc
enta
gePe
rcen
tage
Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by Risk Factors
These graphs illustrate outcomes of exotropia surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear, during calendar years 2013 and 2012, when data collection began. Outcomes were graded as excellent, good, or poor, based on criteria determined by the primary goal of surgery. The results were then secondarily stratified based on the presence or absence of associated risk factors.
This figure presents outcomes for exotropia surgery in patients with or without associated risk factors. Risk factors included the following: bilateral vision limitation (e.g., albinism), conditions resulting in hyper- or hypotonia, craniosynostosis or craniofacial anomalies, 3rd nerve palsy, 4th nerve palsy, prior strabismus surgery, Duane syndrome, prior surgery for retinal detachment, Graves’ orbitopathy, antecedent orbital trauma with or without orbital fracture, congenital fibrosis of the extraocular muscles and simultaneous surgery for nystagmus or vertical strabismus.
%Excellent %Good %Poor
%Excellent %Good %Poor
BinocularPotential
2012(N = 28)
2013(N = 29)
2012No RiskFactors
(N = 25)
2012Risk
Factors(N = 3)
2012No RiskFactors(N = 5)
2012Risk
Factors(N = 9)
2013No RiskFactors
(N = 17)
2013Risk
Factors(N = 12)
2013No RiskFactors(N = 5)
2013Risk
Factors(N = 3)
2012No RiskFactors
(N = 40)
2012Risk
Factors(N = 38)
2012No RiskFactors
(N = 72)
2012Risk
Factors(N = 50)
2013No RiskFactors
(N = 25)
2013Risk
Factors(N = 35)
2013No RiskFactors
(N = 47)
2013Risk
Factors(N = 50)
2012(N = 78)
2013(N = 60)
2012(N = 14)
2013(N = 8)
2012(N = 122)
2013(N = 97)
Binocular Potential
Reconstructive
Reconstructive
Diplopia
Diplopia
Overall
Overall
72.0
8.0
20.033.3
66.7
47.1
29.4
23.533.3
5.015.8
4.0
20.09.7 14.0 10.6
24.0
16.7
10.0
18.4
4.0
2.933.3 9.7
14.012.8
6.0
50.0
85.0
65.8
92.0
77.1
100.0 100.0 100.0
66.7
80.672.0 76.6
70.0
Of 146 patients with esotropia,
62 underwent surgery to
restore binocular vision, 63
for reconstructive goals, and
21 to resolve diplopia.
Of the 146 patients with
esotropia who underwent
strabismus surgery in 2013,
64 patients had associated
risk factors.
37
Pediatric and Adult Strabismus Surgery: Esotropia Outcomes Stratified by Goal
100
80
60
40
20
0
100
80
60
40
20
0
23.9
9.9
66.280.6
9.7
9.7 13.3
10.0
76.785.7
9.5
4.8
80.0
20.0
95.2
4.8
19.0
8.5
72.584.9
6.2
8.9
Perc
enta
gePe
rcen
tage
Pediatric and Adult Strabismus Surgery: Esotropia Outcomes Stratified by Risk Factors
These graphs illustrate outcomes of esotropia surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear, during calendar years 2013 and 2012, when data collection began. Outcomes were graded as excellent, good, or poor, based on criteria determined by the primary goal of surgery. The results were then secondarily stratified based on the presence or absence of associated risk factors.
This figure presents outcomes for esotropia surgery in patients with or without associated risk factors. Risk factors included the following: prior strabismus surgery, bilateral vision limitation (e.g., albinism), systemic conditions resulting in hyper- or hypotonia, craniosynostosis or craniofacial anomalies, Graves’ orbitopathy, antecedent orbital trauma with or without orbital fracture, prior surgery for retinal detachment, heavy eye syndrome, Brown syndrome, Duane syndrome, 6th nerve palsy, preoperative esotropia ≥ 50 prism diopters, congenital fibrosis of the extraocular muscles, and simultaneous surgery for nystagmus or vertical strabismus.
%Excellent %Good %Poor
%Excellent %Good %Poor
BinocularPotential
2012(N = 71)
2013(N = 62)
2012No RiskFactors
(N = 52)
2012Risk
Factors(N = 19)
2012No RiskFactors(N = 3)
2012Risk
Factors(N = 17)
2013No RiskFactors
(N = 49)
2013Risk
Factors(N = 13)
2013No RiskFactors(N = 9)
2013Risk
Factors(N = 12)
2012No RiskFactors
(N = 31)
2012Risk
Factors(N = 29)
2012No RiskFactors
(N = 86)
2012Risk
Factors(N = 67)
2013No RiskFactors
(N = 24)
2013Risk
Factors(N = 39)
2013No RiskFactors
(N = 82)
2013Risk
Factors(N = 64)
2012(N = 60)
2013(N = 63)
2012(N = 20)
2013(N = 21)
2012(N = 153)
2013(N = 146)
Binocular Potential
Reconstructive
Reconstructive
Diplopia
Diplopia
Overall
Overall
67.3
9.6
23.1
63.2
10.5
26.3
81.6
10.2
8.2
76.9
7.7
15.4
77.4
9.7
12.9
75.9
10.3
13.8
79.2
8.3
12.5
89.7
2.67.7
100.0
76.5
23.5
100.0
91.7
8.3
72.1
9.3
18.6
73.1
7.5
19.4
82.9
8.5
8.5
87.5
3.1
9.4
38
Of the 350 procedures
performed for strabismus
correction, three (0.9%) were
complicated by postoperative
infections within 30 days of
the procedure. There were no
cases of associated vision loss.
Of the 367 strabismus
procedures performed, two
(0.54%) were complicated by
scleral perforation and
associated retinal hole. Both
were treated with laser
retinopexy, and neither case
developed retinal detachment.
Pediatric and Adult Strabismus Surgery: Scleral Perforation During Strabismus Surgery
Pediatric and Adult Strabismus Surgery: Infection Within 30 days After Surgery
10
8
6
4
2
0
10
8
6
4
2
0
Rat
e of
Scl
eral
Per
fora
tion
(%
)Po
stop
erat
ive
infe
ctio
n ra
te (
%)
Scleral perforation is a major complication of strabismus surgery, typically occurring during the reattachment of the eye muscles to the globe. An associated retinal hole can give rise to retinal detachment in some cases. This figure demonstrates the scleral perforation rate for strabismus surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear during calendar year 2013.
Infection after intraocular or extraocular surgery may be complicated by postoperative infection. This figure demonstrates the postoperative infection rates for strabismus, cataract, and ptosis surgeries performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear during calendar year 2013.
0.54%
0.9%0.0% 0.0%
2013 (N = 367)
StrabismusSurgery
(N = 350)
PediatricCataractSurgery(N = 83)
PtosisSurgery(N = 40)
39
For the past two years, the
Mass. Eye and Ear Neuro-
Ophthalmology Service has
maintained favorable rates of
follow-up for results of
outpatient imaging studies
compared to published
guidelines and international
benchmarks.
Of the 373 scans that were
ordered by a physician in the
Neuro-Ophthalmology Service
and also completed at Mass.
Eye and Ear in 2013, 354 scans
(94.9%) had documentation of
when the patient was notified
of the test results. Similar
results were reported for
calendar year 2012, during
which time 96.6%(348/360)
of scans had documentation
of follow-up with the patient.
A review of the literature
revealed that physicians
document their follow-up
with patients for 64.3% to
100% of scans ordered.4,5
Neuro-Ophthalmology: Imaging Study Results to Patients
During calendar year 2013, the Mass. Eye and Ear Neuro-Ophthalmology Service ordered
407 outpatient neuroimaging scans (e.g., MRI, CT scans, etc.). Thirty-four of these scans
were excluded from analysis because they were cancelled (21) or performed at outside
hospitals (13). This left a total of 373 scans for the current analysis. Follow-up rates reflect
the length of time from when the scan was performed to when the ordering physician
was able to successfully reach the patient (not necessarily the first call to the patient).
Of the 373 imaging studies included in the 2013 analysis, scan follow-up rates were
as follows: 102 scans (27.3%) were reviewed with the patient within one business day;
151 (40.5%) within two business days; 309 (82.8%) within seven calendar days; and
352 (94.4%) within 14 calendar days.
To the best of our knowledge, there are no ophthalmology studies that report the
percentage of patients who receive imaging results at specified time points. The Veterans
Health Administration (VHA) published guidelines in 2009 stating that all test results should
be given to patients within 14 calendar days after the test results are made available to the
physician. Similar guidelines have been published in the European community.1-3
References: 1Singh H, Vij M. Eight recommendations for policies for communicating abnormal test results. The Joint Commission
Journal on Quality and Patient Safety 2010; 36(5): 226-232. 2Sittig D, Singh H. Improving test result follow-up through electronic
health records requires more than just an alert. J Gen Intern Med 2012; 27(10): 1235–7. 3Rosenberg R et al. Timeliness of follow-
up after abnormal screening mammogram: variability of facilities. Radiology 2011; 261(2): 404-413. 4Callen J et al. Failure to
follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med 2011; 27(10): 1334-48. 5Casalino LP et al.
Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009; 169(12): 1123-1129.
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
2012 (N = 360)*
2013 (N = 373)
* Additional scans were identified for
calendar year 2012 that were not reported
in the previous publication. Inclusion of
these cases changed the rate of follow-up
within 24 hours from 150/348 (43.1%)
to 150/360 (41.7%); follow-up within 48
hours from 203/348 (58.3%) to 203/360
(56.4%); and within seven days from
327/348 (94%) to 327/360 (90.8%).
41.7%
27.3%
56.4%
40.5%
90.8%
82.8%
Within 24 business hours
Within 48 business hours
Within 7 calendar days
40
On January 2, 2013, the
Mass. Eye and Ear Neuro-
Ophthalmology Service
launched a patient satisfaction
survey to prospectively
evaluate the patient experience
in the Neuro-Ophthalmology
Clinic. The voluntary survey
was completed by 295 patients
during the 2013 calendar year.
The results summarized here
reflect the responses of 165
new patients and 130
established patients, 55.9%
and 44.1%, respectively.
Prior to every appointment in
the Neuro-Ophthalmology
Clinic, patients are given
detailed information and
instructions to better prepare
them for the visit. These
instructions explain to the
patient that Neuro-
Ophthalmology visits are much
longer than most doctor visits,
that it is important to bring past
imaging studies (i.e., MRI or CT
scans), and that the dilated eye
exam will make their vision
blurry for a few hours after the
eye exam is completed. These
instructions are meant to better
inform the patients.
Neuro-Ophthalmology Service: Patient Satisfaction Survey
100
80
60
40
20
0
100
80
60
40
20
0
Excellent (N = 243)
Very Good (N = 47)
Good (N = 5)
Substandard (N = 0) N = 295
Excellent (N = 194)
Very Good (N = 63)
Good (N = 33)
Substandard (N = 5) N = 295
Excellent (N = 257)
Very Good (N = 33)
Good (N = 5)
Substandard (N = 0) N = 295
When asked to rate the overall quality of service, 290 patients (98.3%) responded that the quality of service in the Neuro-Ophthalmology Clinic was either “Excellent” or “Very Good.” The response options are indicated in the graph on the left.
When asked to rate the clarity of instructions that are given prior to their Neuro-Ophthalmology appointments, 87% of patients (257) responded that the clarity of the instructions was either “Excellent” or “Very Good.”
Two hundred ninety patients (98.3%) rated the friendliness and courteousness of the Neuro-Ophthalmology physicians as either “Excellent” or “Very Good.”
Qua
lity
of S
ervi
ce (
%)
Frie
ndlin
ess
of P
hysi
cian
s (%
)
82.4%
87.1%
15.9%
11.2%
1.7%
1.7%
0.0%
0.0%
100
80
60
40
20
0
Cla
rity
of
Inst
ruct
ions
(%
)
65.8%
21.4%11.2%
1.5%
41
100
80
60
40
20
0
Based on their experience, 286 patients (97%) said they would be either “Extremely Likely” or “Very Likely” to recommend the Mass. Eye and Ear Neuro-Ophthalmology Service to others.
Like
ly t
o R
ecom
men
d (%
) 83.1%
13.9%2.7% 0.3%
Excellent (N = 238)
Very Good (N = 49)
Good (N = 8)
Substandard (N = 0) N = 295
100
80
60
40
20
0
Frie
ndlin
ess
of S
taff
(%
) 80.7%
16.6%
2.7% 0.0%
Two hundred eighty seven patients (97.3%) responded that the friendliness and courteousness of the administrative staff was “Excellent” or “Very Good.”
Extremely Likely (N = 245)
Very Likely (N = 41)
Likely (N = 8)
Not Likely (N = 1) N = 295
42
Ocular Immunology and Uveitis Service: Percentage of Patients on Systemic Immunomodulatory Therapy
50
40
30
20
10
0
Pati
ents
tre
ated
wit
h sy
stem
ic m
edic
atio
ns (
%)
The Mass. Eye and Ear Ocular Immunology and Uveitis Service saw a total of 2,635 patients over 6,183 office visits during the 2013 calendar year. The calendar year 2013 data depicted here only includes the 1,724 patients seen at the main Boston campus. Of the 1,724 patients seen in 2013 by the Ocular Immunology and Uveitis Service, 469 patients (27.2%) were treated for ocular inflammation with some form of systemic medication, ranging from prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen, etc.) to oral corticosteroids (i.e., prednisone) to immunosuppressive agents (e.g., methotrexate, mycophenolate mofetil, etc.). The significant increase from 2012 to 2013 in the percentage of patients on systemic therapy for control of their ocular inflammatory disease could be partly explained by limiting the analysis to patients seen at the main hospital (a population of patients with more severe disease).
19.5%
27.2%
2012 (N = 2,525)*
2013 (N = 1,724)
* Data reported for the 2012
calendar year includes all patients
seen by the Uveitis Service at
any Mass. Eye and Ear location.
For calendar year 2013 data, the
graphed data depicts only patients
who were seen at the main
Boston hospital.
Treatment for uveitis (i.e.,
inflammation inside the eye) and
other ocular inflammatory
conditions requires a multi-
disciplinary approach that
involves internal medicine and
ophthalmology. At the Mass. Eye
and Ear Ocular Immunology and
Uveitis Service, patients are
treated with a range of
therapies, including topical eye
drops, prescription NSAIDs, and
systemic immunosuppressive
medications. In general, the use
of systemic immunomodulatory
therapy is an indicator of
increased disease severity.
(left) Photo of the right eye
of a patient with peripheral
ulcerative keratitis (PUK)
Photo courtesy of
George Papaliodis, M.D.
43
Vision Rehabilitation Service: Vision-Specific Quality of Life Outcomes
Patients reported
improvement on all IVI
subscales with the greatest
improvement for reading.
3.0
2.0
1.0
0.0
IVI v
isio
n-sp
ecif
ic
qual
ity
of li
fe m
ean
scor
es When completing the Impact of Vision Impairment (IVI) questionnaire, patients are asked to rate if their eyesight interferes with everyday activities: (0) not at all, (1) a little, (2) a fair amount, or (3) a lot of the time. Lower scores represent better visual functioning.
Pre-Rehabilitation (N = 82)
Post-Rehabilitation (N = 82)
Total Reading Mobility Well-being
1.431.19
1.541.22
1.421.20
1.471.27
During 2013, 82 patients were enrolled in a prospective database and completed two questionnaires both prior to, and after, rehabilitation. Patient scores on both the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and the Impact of Vision Impairment (IVI) questionnaire indicate that many aspects of daily life and patients’ adjustment to vision loss are positively impacted by comprehensive vision rehabilitation. Mean scores of four NEI VFQ-25 subscales are displayed above with 100 being the best reported function.1 Changes post-rehabilitation are consistent with previously reported studies of vision rehabilitation outcomes.2,3
References: 1Mangione CM et al. Psychometric properties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ).
NEI-VFQ Field Test Investigators. Arch Ophthalmol. 1998;116(11):1496-504. 2Scott IU et al. Quality of life of low-vision patients
and the impact of low-vision services. Am J Ophthalmol 1999; 128:54-62. 3Kuyk T et al. Health-related quality of life following
blind rehabilitation. Qual Life Res 2008; 17:497-507.
100
90
80
70
60
50
40
30
20
10
0
NEI
VFQ
-25
visi
on-s
peci
fic
qual
ity
of li
fe m
ean
scor
es
Pre-Rehabilitation (N = 82)
Post-Rehabilitation (N = 82)
Previous Reported Outcome Studies2,3
General vision Near vision activities Mental health Dependency
45.0
51.4
41.4
49.0
42.3
50.355.6
61.8
The four NEI VFQ-25
subscales with greatest
improvement were general
vision, near vision, mental
health, and dependency.
55-57
45-66 45-54
57-66
30-38
39-46 46-59
34-43
44
100
80
60
40
20
0
Ninety-five percent of patients reported that the explanation of their rehabilitation options was either “Excellent” or “Above Average.”
Excellent (N = 229)
Above Average (N = 21)
Average (N = 9)
Poor (N = 0)
No Response (N = 3) N = 262
Expl
anat
ion
of
reha
bilit
atio
n op
tion
s (%
) 87.4%
8.0% 3.4% 1.1%0.0%
100
80
60
40
20
0
Excellent (N = 250)
Above Average (N = 12)
Average (N = 0)
Poor (N = 0) N = 262
One hundred percent of patients rated their interactions with staff as “Excellent” or “Above Average.”
Inte
ract
ion
wit
h st
aff
(%)
95.4%
4.6%0.0% 0.0%
Based on their experience,
99% of patients said they
would recommend the
Mass. Eye and Ear Vision
Rehabilitation Service to
friends or family.
99% of patients treated by
the Vision Rehabilitation
Service rated the quality
of service as either “Excellent”
or “Above Average.”
100
80
60
40
20
0
The Mass. Eye and Ear Vision Rehabilitation Service offers multidisciplinary Comprehensive Vision Rehabilitation tailored to each patient’s unique goals. Interventions address difficulties with reading, activities of daily living, and patient safety. Interventions help patients to continue participation in activities despite vision loss, and visits also address the psychosocial adjustment to low vision. During 2013, 262 patients completed a six-question survey after their initial consultation.
Excellent (N = 236)
Above Average (N = 24)
Average (N = 2)
Poor (N = 0) N = 262
Qua
lity
of S
ervi
ce (
%)
90%
9.2%0.8% 0.0%
Vision Rehabilitation Service: Patient Satisfaction Survey
Massachusetts Eye and Ear
O T O L A R Y N G O L O G Y D E P A R T M E N T
45
The Mass. Eye and Ear/Harvard Medical School Department of
Otolaryngology combines the expertise of highly specialized
otolaryngology physicians, audiologists, speech-language pathologists
and auxiliary healthcare professionals to provide clinical care for patients
with problems affecting the ear, nose, throat, head and neck areas. Our
clinical commitment is strengthened by our robust research presence,
as our physicians and scientists work together to advance the care we
provide to our patients.
Mass. Eye and Ear/Harvard Medical School Department of Otolaryngology is firmly
committed to delivering excellence in clinical care, research and teaching. We provide
comprehensive medical and surgical care in a variety of subspecialties in the field of
otolaryngology, including:
• General Otolaryngology
• Pediatric Otolaryngology
• Audiology
• Otology and Neurotology
• Otoneurology
• Vestibular Disorders
• Head and Neck Oncology
• Laryngology
• Rhinology
• Facial Plastic and Reconstructive Surgery
• Facial Nerve Disorders
• Dermatology
• Laser Reconstructive Surgery
• Thyroid and Parathyroid Endocrine Surgery
We are also a center of research in these areas of expertise, with one of the largest and
most productive communities of otolaryngology researchers anywhere in the world. We
have a long history of medical breakthroughs, including the discovery of stem cells in
the adult inner ear and the ability to screen infants at birth for deafness. Our physicians
and scientists are committed to advancing the care we provide to our patients.
Department Highlights
• Primary teaching hospital and coordinating center for Harvard Medical School’s
Residency Program in Otolaryngology – Head and Neck Surgery.
• Home to a large community of otolaryngology researchers, including those
from the Eaton-Peabody Laboratories of Auditory Physiology, Jenks Vestibular
Physiology Laboratory, Jenks Vestibular Diagnostic Laboratory, Amelia Peabody
Otoimmunochemistry Laboratory, Otopathology Laboratory, Norman Knight Center
for Hyperbaric Medicine, National Temporal Bone, Hearing and Balance Pathology
Resource Registry, Facial Nerve Regeneration Laboratory, Carolyn and Peter Lynch
Center for Laser and Reconstructive Surgery and the Tillotson Cell Biology Unit.
46
Department of Otolaryngology Massachusetts Eye and Ear, Harvard Medical School
For more information about
the Mass. Eye and Ear Quality
Program or the Department
of Otolaryngology, please
visit our website at
www.MassEyeAndEar.org.
Clinical Affiliations
• Massachusetts General Hospital (MGH)
- Mass. Eye and Ear physicians and audiologists provide comprehensive and
subspecialty care, including consultations and coordination of inpatient
consultations for urgent patient care concerns and newborn infant auditory
screening.
• Brigham and Women’s Hospital (BWH)
- Mass. Eye and Ear provides otology/neurotology subspecialty support to the
Otolaryngology Division of BWH.
• Mass. Eye and Ear Suburban Centers for Otolaryngology
- Mass. Eye and Ear physicians and audiologists provide comprehensive community-
based care throughout the greater Boston area, with locations in the Longwood
Medical Area of Boston, Braintree, Concord, Duxbury, East Bridgewater, Medford,
Milton, Newton-Wellesley, Quincy, Stoneham and Weymouth.
• Mass. Eye and Ear Balance and Vestibular Center at Braintree Rehabilitation Hospital
- Mass. Eye and Ear specialists provide comprehensive vestibular diagnostic
services, as well as otologic and neurologic assessment and care in a specialty
clinic housed at the Braintree Rehabilitation Hospital.
Academic Affiliations
• Massachusetts General Hospital
• Brigham and Women’s Hospital
• Beth Israel Deaconess Medical Center
• Boston Children’s Hospital
Otolaryngology Resources at Mass. Eye and Ear
• Full spectrum of primary and subspecialty otolaryngology care.
• Highly skilled clinical and research teams in each area.
• New England’s only dedicated otolaryngology emergency services with staff coverage
24 hours a day, 7 days a week and available for walk-ins.
• Audiology Department, providing a full range of diagnostic and treatment services
for patients with hearing loss, including newborn screening, audiometry, hearing aid
services and cochlear implant and auditory rehabilitation services for adults and children.
• Clinical Vestibular Testing, offering an array of the latest equipment and highly trained
staff to aid in diagnosis of vestibular and balance disorders in the Jenks Vestibular
Diagnostic Laboratory and at the Mass. Eye and Ear Balance and Vestibular Center
in Braintree.
47
• Facial Nerve Center, offering full diagnostic, surgical and rehabilitative services for
patients with facial paralysis and movement disorders.
• Mohs Cutaneous Surgery Unit and Carolyn and Peter Lynch Center for Laser and
Reconstructive Surgery, providing care for a wide array of dermatologic disorders
and cancer.
• Head and Neck Oncology, providing the most up-to-date and effective evaluation
and treatment modalities for patients with head and neck cancer, including medical
oncology, microvascular surgery and collaboration with MGH radiation oncology
and proton beam facilities.
• Thyroid and Parathyroid Endocrine Surgery, offering diagnostic and surgical care
for patients with thyroid and parathyroid diseases of the head and neck, with world-
renowned expertise in nerve preservation and electrophysiological intraoperative
monitoring.
• Pediatric Airway, Voice and Swallowing Center, performing assessments and
treatment of a wide spectrum of these congenital, developmental and acquired
disorders in children.
• Voice Rehabilitation and Therapy, providing care for patients suffering from laryngeal
cancer, laryngeal motion disorders, hoarseness, papillomatosis and keratosis
and airway and voice disorders. Physicians work closely with speech-language
pathologists in the Mass. Eye and Ear Voice and Speech Laboratory, which provides
state-of-the-art audio and video diagnostic facilities, technicians and therapists.
• Sinus Center, providing clinical care to patients with all diseases of the nose
and sinuses.
• Sleep Center, providing polysomnography sleep diagnostic studies for assessment of
adults and children with sleep disturbances.
• Fully integrated access to all hospital support services and infrastructure, including
social work and discharge planning, the Howe Library, clinical and research IT, medical
unit, infectious disease unit, radiology unit, child life specialists, surgical pathology
unit, international program and language translation support, dietary support and
pharmacy services.
48
Distribution of Otolaryngology Diagnoses
Data was collected and analyzed from 12,234 patients who received a diagnosis for an otolaryngologic complaint in the Mass. Eye and Ear Emergency Department between January 2011 and September 2013. The most frequent presenting complaints were related to the auditory or vestibular system (50.0%) (Figure 1). The five most common were impacted cerumen (10.8%), otitis externa (8.9%), otitis media (6.9%), epistaxis (6.0%) and hearing loss (5.6%) (Table 1).
Figure 1: Distribution of head and neck systems by frequency of presenting complaints
Table 1: Ten most common diagnoses among all patients
Diagnosis All Patients (N=12,234)
Impacted cerumen, No. (%) ......................................................................................................................1,322 (10.8)
Otitis externa, No. (%) ....................................................................................................................................... 1,085 (8.9)
Otitis media, No. (%) .................................................................................................................................................840 (6.9)
Epistaxis, No. (%)............................................................................................................................................................731 (6.0)
Hearing loss, No. (%) .................................................................................................................................................687 (5.6)
Sinusitis, No. (%) .............................................................................................................................................................547 (4.5)
Otalgia, No. (%) ..............................................................................................................................................................495 (4.1)
Dizziness or vertigo, No. (%) .............................................................................................................................362 (3.0)
Trauma, No. (%) ..............................................................................................................................................................354 (2.9)
Tonsillitis, No. (%) ..........................................................................................................................................................342 (2.8)
49
Mass. Eye and Ear provides
the region’s only dedicated
otolaryngology emergency
services with staff coverage 24
hours a day and 7 days a week.
The department provides care
for otolaryngology emergencies
on a walk-in basis.
Emergency Department: Otolaryngology
Other7%
Oral Cavity1%
Auditory/vestibular50%
Nasal/sinus12%
Pharyngealesophageal
11%
Post-operative5%
Skin/joints4%
Trauma3%
Neck2%
Neurological2%
Laryngeal2%
Facial/glands1%
The Emergency Otolaryngology
Service at Mass. Eye and Ear
works in collaboration with
Mass General, which is
accessible to patients with
broader or associated medical
issues.
Distances Traveled for Specific Diagnoses
at the Massachusetts Eye and Ear Emergency Department
Patients originated from 42 states, although 93 percent were from Massachusetts. More than ninety percent of patients lived within a 50-mile radius of the Mass. Eye and Ear Emergency Department. For all patients, median travel distance was 9.6 miles. Established patients (9.4 miles) and new patients (9.6 miles) traveled similar distances (P=0.535). Visitors traveled similar distances for pediatric care (9.5 miles vs. 8.3 miles for an adult, P=0.811). Patients were willing to travel farther to seek specialized otolaryngologic care if it was a weekend (11.1 miles vs. 8.2 miles on a weekday, P<0.0001). Patients with hearing loss (11.1 miles) and trauma (10.3 miles) traveled the farthest, whereas those with impacted cerumen (7.1 miles) traveled the least (P<0.0001) (Figure 2).
Reference: Sethi R et al. Subspecialty emergency room as alternative model for otolaryngologic care: Implications for emergency
health care delivery. Am J Otolaryngol. 2014 Jul 10; pii: S0196-0709(14)00147-1.
50
MEEI
Less than 19
19-267
267-3712
3712 and above
Min: 6 (019)
Max: 3991 (017)
12
10
8
6
4
2
0ImpactedCerumen
Epistaxis OtitisExterna
PTA Sinusitis Trauma Hearing Loss
Med
ian
Trav
el D
ista
nces
(m
iles)
The Pediatric Otolaryngology Division is dedicated to delivering specialized care in the
treatment of pediatric patients suffering from ear, nose and throat conditions. These
conditions vary from routine to complex, including ear and sinus infections, obstructive
or infectious problems of the tonsils and adenoids, malformations of the head and neck,
hearing and language disorders and breathing and voice problems.
Postoperative Tapering of Medication to Prevent Sedation Withdrawal Symptoms
All patients undergoing laryngotracheal reconstruction (LTR) require postoperative tapering of sedation medication to prevent complications, especially sedation withdrawal symptoms. As part of ongoing quality initiatives, the Pediatric Otolaryngology Division implemented a standardized electronic sedation document and new training related to sedation medications for physicians, nurses and other health care providers. The initiative called for a real time, active decision-making process at the time of patient transfer from the pediatric intensive care unit to the floor setting. Over a two-year period, we examined the sedation wean in 29 consecutive pediatric patients who underwent LTR. With the new system-wide change, the mean length of sedation wean was reduced from 16.19 days to 8.92 days (p<0.05).1 Additionally, the number of patients requiring a narcotic prescription at the time of discharge decreased from 81.3 percent to 33.3 percent (p<0.05).1
References: 1Kozin ED et al. System-Wide Change of Sedation Wean Protocol Following Pediatric Laryngotracheal Reconstruction.
JAMA Otolaryngol Head Neck Surg. 2014 Oct 30. doi: 10.1001/jamaoto.2014.2694. 2Schall M et al. Guide for Field Testing:
Creating an Ideal Transition to the Clinical Office Practice. Institute for Healthcare Improvement 2009.
51
Using the Institute for
Healthcare Improvement (IHI)
methodology,2 the Pediatric
Airway, Voice and Swallowing
Center formed a multidisciplinary
team, including attending
pediatric otolaryngologists,
pediatric intensivists, hospitalists,
fellows, residents, nurses,
pharmacists and social workers to
address issues related to sedation
taper at Mass. Eye and Ear and
Mass General.
The team implemented a
system-wide process change that
significantly reduced the time
required for sedation wean and
decreased the number of
patients leaving the hospital
with a narcotic prescription.
Pediatric Otolaryngology
2011-2012 2012-2014
18
16
14
12
10
8
6
4
2
0
Wea
n D
urat
ion
(day
s)
Duration of Narcotics Wean after
Laryngotracheal Reconstruction
2011-2012 2012-2014
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge (
%)
Patients Undergoing Laryngotracheal
Reconstruction Requiring Narcotic
Prescription at Discharge
Decannulation Rates in Pediatric Airway Surgery
A new technique for laryngotracheal reconstruction (LTR) to treat pediatric airway stenosis has been developed and implemented in the past three years at Mass. Eye and Ear. This technique, known as the hybrid or 1.5-stage LTR, combines aspects of both the single- and double-stage LTRs in order to improve outcomes while minimizing complications. It is particularly useful in the subset of patients who have poor lung function, multilevel airway obstruction, or developmental delay, as they would likely need a tracheostomy tube for additional reasons. However, this technique prevents the complication of airway inflammation and formation of granulation tissue from stent placement, as seen with the double-stage technique. From July 2011 to December 2013, thirteen patients underwent airway reconstruction using this technique. Of those patients, eight were decannulated within twelve months of surgery. Of those who were not decannulated, one required fundoplication for severe reflux, followed by revision LTR and is now preparing for decannulation; one has chronic lung disease preventing decannulation; one has severe tracheomalacia after tracheoesophageal fistula repair; one has severe stenosis after a motor vehicle accident; and one is currently preparing for decannulation. Including the two patients who are currently ready for removal of the tracheostomy tube, operation-specific and overall decannulation rates of 69.2% and 76.9%, respectively, are noted.
When compared to other published reports of patients undergoing single-stage LTRs (operation-specific and overall extubation rates = 80.2% and 93.4%, respectively), the decannulation rate in these patients is slightly lower due to other comorbidities. When compared to double-stage LTRs (operation-specific and overall decannulation rates = 50% and 80.2%, respectively), the results are similar. The hybrid laryngotracheal reconstruction is a useful technique in a subset of pediatric patients with airway stenosis. Early results suggest that the technique has comparable rates of decannulation without the complications seen in single- or double-stage LTR, which are the techniques performed in a similar patient population.
Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, September 2014, Orlando, FL.
References: 1Smith LP et al. Single- vs double-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 2010
Jan;136(1):60-5. 2Hartnick CJ et al. Surgery For Pediatric Subglottic Stenosis: Disease-Specific Outcomes. Ann Otol Rhinol
Laryngol. 2001;110:1109-13.
Physicians in the Pediatric
Airway, Voice and Swallowing
Center at Mass. Eye and Ear
developed this new technique—
hybrid laryngotracheal
reconstruction—by combining
aspects of both the single- and
double-stage laryngotracheal
reconstruction surgeries. Early
results show that the “hybrid”
method may lead to fewer
complications and better
outcomes.
52
Rate of decannulation
Decannulated/ready for decannulation
Narrow airway
Chronic lung disease
The Audiology Department at Mass. Eye and Ear provides a full range of diagnostic
and treatment services for patients with hearing loss, including newborn screening,
audiometry, hearing aid services and cochlear implant and auditory rehabilitation
services for adults and children.
New Variable Predicts Hearing Aid Ownership
Logistic Regression Model: Word Recognition Performance v. Hearing Aid Ownership
Market surveys show that only 22% of those with hearing loss own hearing aids. This “rejection” is often ascribed to non-auditory factors like stigma, cosmetics and cost. However, our recent work shows that an auditory criterion — improved word recognition — predicts which patients will acquire hearing aids. We tabulated hearing aid ownership in 1,000 consecutive patients. We separated patients with hearing loss into two groups: one in which word recognition for soft speech (40 dB HL) could improve with gain supplied by a hearing aid, and another in which it did not. Both groups had audiometric thresholds within established fitting ranges. Like the national sample, exactly 22% of the hearing loss patients we sampled owned hearing aids. However, regardless of where patients received their hearing care, the group whose word recognition scores did not improve with level owned hearing aids at a rate of only 0.3%, while those whose word recognition could increase owned hearing aids at a rate of 50%. Results fit a logistic model where shift of the word recognition performance curve with level corresponded to the likelihood of ownership (see figure). These results provide a better market penetrance model and use audiologic data in a way that better predicts patient outcomes.
References: Kochkin S. MarkeTrak VIII: 25-year trends in the hearing health market. Hear Rev 2009; 16: 12–31.
Halpin C., Rauch S. Improvement in word recognition score with level is associated with hearing aid ownership among patients
with hearing loss. Audiol. Neurotol. 2012 17:139-147.
53
Hearing aid manufacturers
provide audiometric threshold
loss criteria (fitting ranges) as
guidelines for fitting hearing aids
to patients. These are easy to
apply, but provide only a glimpse
at the patient’s potential for
benefit.
We found that a different
hearing variable, improved word
recognition with level, is
consistent with ownership
outcomes. Using this variable
clinically results in a more
conservative fitting criterion, but
one that may better identify
those who can benefit from
hearing aid use.
Audiology
1.00
0.75
0.50
0.25
0.00
Level (dBHL) of 50% Predicted Performance [SII]
0 25 50 75 100 125
Prob
abili
ty o
f O
wne
rshi
p
normal word performance (in quiet)
Physicians in the Otology and Neurotology Division focus on the structure and
function of the ear, as well as the nerves that connect the ear and the brain. They offer
treatment and rehabilitation strategies for a complete range of disorders of the ear.
Superior Semicircular Canal Dehiscence Syndrome (SSCD) Outcomes
In superior semicircular canal dehiscence syndrome (SSCD), the superior canal of the inner ear is missing a portion of its bony covering. This condition may be congenital or acquired and may result in a number of bothersome symptoms, including aural fullness and pressure in the affected ear, imbalance, autophony or tinnitus. If symptoms are debilitating enough, patients may undergo a surgical repair of the bone with plugging of the affected canal. Variation in the location of the bony dehiscence means that patients may require different surgical approaches.
Originally published in “Radiologic Classification of Superior Canal Dehiscence: Implications for Surgical Repair.” Otol Neurotol.
2014 Aug 13. Lookabaugh S et al.
54
Otology and Neurotology
Intact SSC
Bone overlying SSC
Ampulla
Arcuate eminence defect
Bone overlying SSC
Ampulla
55
SSCD may result in a number
of bothersome symptoms,
including aural fullness (pressure
in the affected ear), dizziness or a
spinning sensation, autophony
(sensitivity to loud noise) or
tinnitus (pulsating ringing).
A review of surgical outcomes
revealed that auditory symptoms,
especially autophony and
pressure, are alleviated with
surgery for superior semicircular
canal dehiscence syndrome.
A New Classification System
A recent review of three hundred CT scans demonstrating SSCD at Mass. Eye and
Ear has produced a new classification system for SSCD.1 This work will help lead
neurotologic surgeons to better preoperative planning and, hopefully, to better
surgical outcomes.
Patient Symptoms Before and After Surgery for SSCD
An SSCD diagnosis is made based on clinical signs and symptoms, audiometric and balance testing as well as a high-resolution CT scan. Patients may have variable pre-operative complaints. For some individuals, the simple avoidance of triggers (straining, nose blowing) may be sufficient to alleviate their symptoms and may allow them to avoid surgery. Understanding which symptoms are most effectively relieved through surgery is critical for patient counseling. A review of SSCD surgical outcomes at Mass. Eye and Ear revealed that auditory symptoms are significantly reduced postoperatively.2 Patients with pre-existing migraine, disequilibrium, bilateral SSCD and large bony defects may experience a more prolonged recovery, though all of them noted satisfaction with their outcomes and resolution of their chief complaint.3 This information has helped surgeons better select patients for the procedure and also inform patients undergoing surgery of their expected outcomes.
References: 1Lookabaugh S et al. Radiologic Classification of Superior Canal Dehiscence Syndrome: Implications for Surgical Repair.
Otol Neurotol. 2014 Aug 13. [Epub ahead of print] 2Niesten MD et al. Clinical factors associated with prolonged recovery after
superior canal dehiscence surgery. Otol Neurotol. 2012 Jul; 33(5): 824-31. 3Jung DH et al. Dizziness is more prevalent than autophony
among patients who have undergone repair of superior canal dehiscence. Otol Neurotol. 2014 Aug. 13 (Epub before print)
30
25
20
15
10
15
10
5
0Autophony Aural
FullnessImbalance Pressure Tinnitus
Num
ber
of P
atie
nts
Preoperative Postoperative
0
25 25
3
20
24
3
6
19
0
The Vestibular Division at Mass. Eye and Ear brings together otolaryngology and
otoneurology specialists to provide care for patients with vestibular and balance disorders.
Intratympanic Gentamicin Treatment for Ménière’s Disease Drop Attacks
Ménière’s disease is a degenerative inner ear condition causing progressive deafness and repeated attacks of whirling vertigo that can last for hours at a time. In approximately 90% of cases, the vertigo attacks can be controlled conservatively with a combination of diet and lifestyle changes plus medications. However, about 10% of cases require more aggressive treatment, most often by injection of the ototoxic drug gentamicin into the middle ear. Drop attacks are a rare and dangerous variant of Ménière’s disease in which patients are suddenly and violently thrown to the ground by their attacks without warning. Drop attacks have traditionally been treated by surgical labyrinthectomy to remove the balance organs. Of 3,450 patients with Ménière’s disease seen between 2000 and 2012, 320 had intratympanic gentamicin injections. Gentamicin was used to treat 24 cases of drop attacks. Initial control of drop attacks was achieved in 23/24 (95.8%). Only one drug injection was required in 20/24 (83.3%), while 2-4 injections were required in the other three ears. With a follow-up time of 12-120 months (mean = 43.5 months) after treatment, only two patients required subsequent labyrinthectomy for recurrent drop attacks. Gentamicin injections appear to be an excellent method of controlling Ménière’s drop attacks, avoiding the need for surgery in most cases.
Mass. Eye and Ear established
the Vestibular Division in the
Department of Otolaryngology in
July 2014, bringing together
otolaryngology and otoneurology
specialists who share clinical and
research interests in the
vestibular system. Together they
provide services, including state-
of-the-art vestibular diagnostic
testing, at Mass. Eye and Ear’s
main campus and at the Mass.
Eye and Ear Balance and
Vestibular Center at Braintree
Rehabilitation Hospital. In
addition to clinical care, they
engage in clinical and
translational research to improve
the lives of patients with
vestibular and balance disorders,
often in collaboration with
vestibular basic science
researchers. A formal Vestibular
Division offers structural
advantages and further positions
the Otolaryngology Department
at Mass. Eye and Ear as a leader
in this area of expertise.
Vestibular
Patients with Ménière’s disease
controlled medically
Patients with Ménière’s disease
controlled by IT gentamicin
Patients with Ménière’s disease drop
attacks controlled by IT gentamicin
Patients with Ménière’s disease drop
attacks who failed IT gentamicin and
needed labyrinthectomy
Total: 3,450
296
222
3,130
56
Mass. Eye and Ear established
the Vestibular Division in the
Department of Otolaryngology
in July 2014, bringing together
otolaryngology and
otoneurology specialists who
share clinical and research
interests in the vestibular
system. Together they provide
services, including state-of-the-
art vestibular diagnostic testing,
at Mass. Eye and Ear’s main
campus and at the Mass. Eye
and Ear Balance and Vestibular
Center at Braintree
Rehabilitation Hospital. In
addition to clinical care, they
engage in clinical and
translational research to
improve the lives of patients
with vestibular and balance
disorders, often in collaboration
with vestibular basic science
researchers. A formal Vestibular
Division offers structural
advantages and further
positions the Otolaryngology
Department at Mass. Eye
and Ear as a leader in this area
of expertise.
57
The Head and Neck Oncology Division at Mass. Eye and Ear is firmly committed to
providing the highest quality care to patients with the most challenging and severe
malignancies of the head and neck region. For multiple reasons, including the exposure
to bacterially contaminated secretions such as saliva, surgical interventions of this region
are at a significant risk for infectious complications.
Free Flap Surgical Site Infection RatesIn conjunction with our Infectious Disease service, we reviewed 480 free tissue transfer reconstructive surgery cases (our most complex and time consuming surgical procedures for advanced cancers) over a 50-month period to assess our voluntary compliance with recommendations for prophylactic antibiotic use as utilized in other surgical fields as well as the overall infectious complication rate. Historically, infectious complication rates after advanced head and neck surgery are in the 20-40% range. This analysis revealed 99.8% compliance rate with prophylactic antibiotic administration and an infection rate of 13.3%, amongst the lowest reported for free tissue transfer surgery of the head and neck and in the largest series of patients. This data will allow us to institute and evaluate further initiatives designed to lower this relatively low infection rate further, limiting potential patient morbidity.
Author Flaps Cohort SSI Rate SSI Definition SSI Risk Factors
Jones 100 All defects 10% Not reported Not reported
Yang 129 Cancer 28.3% CDC Not reported
Bourget 137 All defects 28% Frank
purulence
Dehiscence, partial
flap failure
Mucke 156 Cancer 40.4% Purulent
discharge
Flap type, duration
of hospital stay,
need for flap
revision
Kamizono 182 Cancer 19% CDC Malnutrition, ASA,
XRT, bone flap
Dassonville 213 All defects 10% Not reported Not reported
Karakida 276 Cancer 40.6% CDC ASA, surgical
duration
Benatar 429 All defects 17% Not reported XRT
Mass. Eye
and Ear study
479 All defects 13.2% CDC None
ASA: American Society of Anesthesiologists CDC: Centers for Disease Control XRT: Radiation Therapy
Head and Neck Oncology
The study of free flap surgical
site infection rates at Mass. Eye
and Ear included the most flaps
(479) and is among the lowest
infection rates (13.2%) in a
comparison of similar series.
Commonly Used Prophylactic Antibiotics in Free Tissue Transfer Reconstructive Surgery
Reference: Durand ML et al. The time course and microbiology of surgical site infections after head and neck free flap surgery.
Laryngoscope. 2014 Nov 25.
Shoulder Function Following Reconstruction with the Supraclavicular Artery Island Flap
The Division of Head and Neck Oncology continues to work toward improving reconstruction following surgery for head and neck cancers. We recently introduced the supraclavicular flap to our institution, and we’ve completed the only reported study to date to describe the objective and subjective outcomes at the donor site from this surgical procedure. We found that this flap harvest has no significant negative impact on overall shoulder function and quality of life. Subjective outcomes from two shoulder specific quality of life tools (Penn and Constant, as shown in the above graph) showed excellent results. Those patients with poorer outcomes also had concurrent neck dissection surgery that impacted shoulder function. Objective outcomes did reveal some limitation in range of motion, but this was equivalent to the non-operated shoulder and there was no loss of strength.
Reference: Herr MW et al. Shoulder function following reconstruction with the supraclavicular artery island flap. Laryngoscope. 2014;
2014 Nov;124(11):2478-83.
58
Continually tracking and
assessing infectious
complications occurring in
association with advanced head
and neck cancer surgery allows
for the institution and evaluation
of evolving protocols to further
decrease the frequency and
negative side effects of these
occurrences. Similarly,
appropriately directed antibiotic
use as part of such protocols can
curtail the evolution of
challenging antibiotic resistant
organisms.
In the right patient, the
supraclavicular artery island flap
provides an excellent
reconstructive option without
creating additional morbidity and
helping to optimize quality of
life. This finding is important
given the morbidity created by a
patient’s cancer.
Ampicillin/Subactam
Clindamycin
Cefazolin
Vanco +/-
Clinda/Levo
Other
None
Excellent
Good
Fair
Poor
2%2%
3%
9%
1% 0.2%
83%
10
8
6
4
2
0Penn Shoulder
ScoreConstant
Shoulder Score
Num
ber
of P
atie
nts
59
The Laryngology Division at Mass. Eye and Ear is one of only a few laryngology centers
worldwide, comprised of physicians and other healthcare professionals dedicated to
treating disorders of the voice box and upper airway in adults.
Spasmodic Dysphonia
Spasmodic Dysphonia is a rare neurological voice disorder that can devastate personally,
socially and professionally. Affecting close to 50,000 people in the United States, it
is a type of focal dystonia, a neurological disease where the brain sends too many
signals causing unwanted movements in the larynx when the person tries to speak,
typically resulting in a strained/strangled voice quality. The larynx functions normally
during breathing, and technically there is nothing “wrong” with the larynx itself. It is a
problem in the brain that happens to affect voice production.
The standard treatment is an injection of Botox® into the muscles of the voice box
every few months in tiny amounts, in an outpatient-awake procedure that takes less
than 1 minute to decrease the force of contraction and improve voice production.
Although the treatment needs to be tailored to each patient’s case, members of the
Laryngology Division reviewed some of the spasmodic dysphonia cases treated at Mass.
Eye and Ear since 1994 in an attempt to summarize the disease course over 19 years.
We tracked close to 100 patients and found the age at first injection was 53 years
(range = 18-87). Seventy percent of these patients were women (age range 21-87) and
30 percent were men (18-87). As expected, the majority of patients (96 percent) had
the adductor-type (squeezing closed type) Spasmodic Dysphonia, while only 4 percent
had the abductor-type (opening type) Spasmodic Dysphonia. The adductor-type is
technically easier to treat, and the following data comes from this group.
We found stability in the disease over time with the mean dose of Botox® rising
from 2.35 units to 2.36 units. This patient cohort underwent an average of 14
injections with a mean time of 182 days between injections. They experienced 4 weeks
of breathiness after the injection followed by 17 weeks of good voice before needing
another injection.
Laryngology
• Botox® treatment for spasmodic
dysphonia is effective, offering
17 weeks of good voice after
4 weeks of breathy voice.
• Long-term Botox® dose
remains stable over years of
treatment for most patients.
• The average patient returned
for re-injection every 182 days.
• The average age at first
injection was 53 years.
• More women are affected
than men (70% women).
• 96 percent had adductor type
spasmodic dysphonia.
• Botox® injections are fast,
well tolerated and restore
good vocal function.
Physicians in the Rhinology Division provide clinical care to patients with all diseases
of the nose and sinuses. They team up with specialists in allergy and immunology,
infectious disease, neurosurgery and radiology to provide a comprehensive approach
to managing nasal and sinus disorders.
Long-Term Outcomes in Sinus Surgery
Problems in Quality of Life
Patients with chronic sinusitis were assessed with validated surveys to better understand the impact of their disease on their quality of life. One instrument, the EuroQol 5-Dimension Assessment (or EQ-5D), was used for the first time in U.S. patients with sinus problems for this study. The EQ-5D provides important initial data on the burden of disease and helps us to quantify our patient outcomes. In this study, individuals with sinusitis were compared to the general U.S. population across quality of life domains. The graph demonstrates that patients with sinusitis report significantly more problems with pain and discomfort, anxiety and depression, as well as problems performing their daily activities than do patients without sinusitis.
Changes in Quality of Life after Sinus Surgery
Patients who underwent sinus surgery at Mass. Eye and Ear were assessed for changes in quality of life postoperatively. Scores in all three domains significantly improved, and this change was noticed up to 2 years after surgery. This study is the first of its kind to quantify changes in quality of life after sinus surgery using the EQ-5D. This information may be used to perform cost-effectiveness analyses and to help make sure that the benefits provided through surgical procedures are worthwhile to patients suffering from sinus diseases.
References: 1Remenschneider AK et al. The EQ-5D
- a new tool for studying clinical outcomes in
chronic rhinosinusitis. Laryngoscope. 2014 Nov 28. 2Remenschneider AK et al. Long-Term Outcomes in
Sinus Surgery: A New Tool for Measuring Health-Related
Quality of Life. Otolaryngol Head Neck Surg. 2014 Apr
4;151(1):164-170.
60
An important study is being
conducted at Mass. Eye and Ear
by Drs. Ralph Metson, Stacey
Gray, and Eric Holbrook; the
“Sinusitis Outcomes Study” is
the first of its kind to examine
quality of life in patients with
sinus disorders using the EQ-5D
survey, a tool that allows for
comparison with other common
diseases. The valuable
information they’ve collected
may be used to analyze cost-
effectiveness and to assess
quality of life benefits following
treatment for sinus disease.
Rhinology
Patients with Chronic Sinusitis — No Surgery
General Population
100
80
60
40
20
0Performing
Daily ActivitiesPain &
DiscomfortAnxiety & Depression
Perc
ent
of P
atie
nts
Rep
orti
ng P
robl
ems
Patients with Chronic Sinusitis Before Surgery
After Surgery
100
80
60
40
20
0Performing
Daily ActivitiesPain &
DiscomfortAnxiety & Depression
Perc
ent
of P
atie
nts
Rep
orti
ng P
robl
ems
61
The Facial Plastic and Reconstructive Surgery Division is dedicated to the aesthetic and
functional enhancement of the head and neck.
Quality of Life Outcomes Following Functional Rhinoplasty in Patients with Nasal Obstruction
(NOSE: Nasal Obstruction Symptoms Evaluation)
Nasal obstruction is one of the most common complaints in otolaryngology practice. From September 2009 to January 2011, 60 patients who presented with nasal obstruction underwent functional rhinoplasty. Patients were asked to complete the Nasal Obstruction Symptom Evaluation (NOSE) and Sleep Outcomes Survey (SOS) questionnaires at 1 month, 3 months, 6 months and 12 months follow up. Both surveys are validated disease-specific QOL instruments used to quantify both patient symptomatology and interventional effect. Twenty-three percent of patients had internal nasal valve dysfunction (group 1), 26.7 percent had external nasal valve dysfunction (group 2) and 50 percent had combined dysfunction (group 3) before surgery. Following surgery, their NOSE and SOS scores indicate an overall significant improvement in quality of life.
Reference: Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope. 2012 Jul;122(7):1480-8. doi:
10.1002/lary.23345. Epub 2012 May 1.
Facial Plastic and Reconstructive Surgery
all subjects
internal nasal valve (Group 1)
External nasal valve (Group 2)
internal and external nasal valve
(Group 3)
Baseline, Mean 1-3 Months, Mean 6-12 Months, Mean
Score
66.42 (SD = 20.25) n = 60
21.85 (SD = 20.68) n = 54
22.33 (SD = 23.05) n = 45
61.79 (SD = 23.34) n = 14
13.46 (SD = 19.19) n = 13
4.09 (SD = 7.35) n = 11
59.60 (SD = 20.69) n = 16
22.69 (SD = 15.22) n = 13
18.85 (SD = 17.34) n = 13
72.17 (SD = 17.30) n = 30
25.36 (SD = 22.93) n = 28
34.05 (SD = 25.03) n = 21
0 10 20 30 40 50 60 70 80
On the NOSE scale, lower scores
indicate improved quality of life
(SOS: Sleep Outcomes Survey)
Quality of Life Outcomes Following Correction of the Alar Base
in Patients with Flaccid Facial Paralysis
(NOSE: Nasal Obstruction Symptom Evaluation Score)
Nasal valve collapse caused by facial palsy is an often overlooked but disturbing sequela of flaccid facial paralysis. From March 2009 to December 2013, physicians in the Facial Nerve Center at Mass. Eye and Ear prospectively studied the effect of placement of a fascia lata sling placement for correction of external nasal valve compromise in 68 patients with flaccid facial paralysis, uti-lizing a validated disease specific quality of life outcome survey, the Nasal Obstruction Symptom Evaluation (NOSE) scale. Ratings were ascertained preoperatively and postoperatively. Sixty patients completed a NOSE survey prior to surgical intervention and 40 completed the survey after intervention. There was a statistically significant difference in NOSE scores after fascia lata sling (Wilcoxin signed-rank test, p<0.001). All patients had improvement in their nasal obstruction, which persisted uniformly in follow-up.
all subjects
internal nasal valve (Group 1)
External nasal valve (Group 2)
internal and external nasal valve
(Group 3)
Score
58.45 (SD = 18.24) n = 60
80.44 (SD = 17.28) n = 50
78.93 (SD = 18.46) n = 46
64.62 (SD = 22.57) n = 14
83.00 (SD = 18.77) n = 11
77.91 (SD = 22.00) n = 11
55.76 (SD = 17.69) n = 16
83.35 (SD = 10.46) n = 10
85.09 (SD = 16.26) n = 13
57.21 (SD = 16.43) n = 30
78.14 (SD = 18.71) n = 27
75.80 (SD = 18.13) n = 22
0 10 20 30 40 50 60 70 80 90
On the SOS scale, higher scores
indicate improved quality of life
On the NOSE scale, lower scores
indicate improved quality of life
62
Preoperative(mean +_ SD)
Postoperative(mean +_ SD)
Score (p-Value: < 0.001)
0 5 10 15 20 25 30 35 40
36.6 (SD = +_ 27.1)
16.76 (SD = +_ 17.37)
Baseline, Mean 1-3 Months, Mean 6-12 Months, Mean
63
Before After
Reference: Prospective Evaluation of Quality of Life improvement after Correction of the Alar Base in the Flaccidly Paralyzed Face.
Lindsay RW et al. (JAMA Facial Plast Surg. 2015 Jan 2. [Epub ahead of print])
The Thyroid and Parathyroid Endocrine Surgery Division at Mass. Eye and Ear strives
to effectively minimize commonly associated risks, including vocal cord paralysis (VCP),
in thyroid and parathyroid endocrine surgery by applying thorough preoperative
evaluation and utilizing nerve monitoring technology during surgery.
Surgical Outcomes in Professional Voice Users
A recent analysis of 27 articles that reviewed more than 25,000 patients undergoing
thyroidectomy found that the average postoperative VCP rate was 9.8% and ranged from
0 to 18.6%.1 VCP following thyroid surgery occurs due to injury to the recurrent laryngeal
nerve (RLN), while other voice-related complications of thyroid surgery arise from injury
to the external branch of the superior laryngeal nerve (EBSLN). Both the RLN and EBSLN
are closely related to the thyroid gland. Injury to the EBSLN can be challenging to identify
intraoperatively. This type of injury can cause easy voice fatigue, decreased pitch and
inability to project voice. Thus, thyroid surgery in professional voice users has much higher
stakes, as it can pose significant risk by affecting their career, livelihood and earning
capacity. VCP may also affect those engaged in religious vocal professions.
The Division recently reviewed surgical outcomes in professional singers/voice users,
the first such series in the world literature, which included many different genres of
performers, including 44% classical/operatic, 19% religious (including 1 Gospel, 1 Jewish
Cantor and 3 Choir), 25% pop/rock, 11% country & blues/folk, 4% Motown, 7% musical
theater performers, 7% music teachers and 7% others (1 voiceover artist and 1 television
meteorologist). Some patients indicated multiple genres of performance (figure 1).
We routinely employ RLN and EBSLN monitoring during surgery to aid in preventing
injuries. In our series of 27 singers and professional voice users, return to performance was
achieved in 100% of patients and the first postoperative performance occurred within
a mean time of 2.26 months from surgery. Vocal instrument mean scores showed no
statistically significant difference in preoperative vs. postoperative voice comparison (figure
2), indicative of successful vocal function preservation. Vocal instruments used were VHI
(voice handicap index), SVHI (singing voice handicap index) and EASE (evaluation of the
ability to sing easily). Most vocal professionals felt that vocal training to some extent was
helpful in their return to professional vocal performance.
Based on this unique series of professional voice users undergoing thyroid surgery,
the Division has identified key elements of operative approach, including RLN and
EBSLN nerve monitoring during surgery, minimum tissue handling and dissection and
pre- and postoperative laryngeal exam to achieve successful preservation of vocal
integrity in the professional voice user. These key elements will offer guidelines to
other thyroid surgeons, enabling them to achieve similar voice outcomes and counsel
professional singers anticipating thyroid surgery.
Reference: 1Jeannon JP et al. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. International
journal of clinical practice. 2009: 63:624-629.
64
Physicians in the Division of
Thyroid and Parathyroid
Endocrine Surgery at Mass. Eye
and Ear are some of the most
experienced in the world, having
performed more than 3,500 cases
of thyroid surgery with
intraoperative nerve monitoring.
Due to this high volume, they
have had extensive, specialized
experience operating on
professional voice users.
Thyroid and Parathyroid Endocrine Surgery
65
Figure 1. Percentages of different genres of professional voice users in the study
(with some patients indicating multiple genres of performance)
Figure 2. Graph shows mean scores of different vocal instruments that were used to
evaluate voice before and after thyroid surgery. No difference was noted in pre- and
postoperative scores.
Comparison of mean preop and postop scores of vocal instruments
(No difference noted in before and after surgery scores)
These surgical outcomes show
that thyroid surgery is safe and
effective for professional voice
users. By following key elements
of operative approach, return to
professional performance after
thyroid surgery can be achieved
in 100% of singers and
professional voice users with the
mean time to return to
professional performance being
2.26 months.
A comparison of preoperative vs.
postoperative voice instrument
scores showed no difference in
quality of life after surgery.
Classical/Operatic
Pop/Rock
Religious
Country and Blues/Folk
Musical theater
Musicteacher
Other
Motown
0 5 10 15 20 25 30 35 40 45 50
44%
25%
19%
11%
7%
7%
7%
4%
Voc
al G
enre
14
12
10
8
6
4
2
0VHI SVHI EASE
Mea
n Sc
ore
Vocal instruments
Preoperative
Postoperative
66
Massachusetts Eye and Ear Infirmary
N U R S I N G D E P A R T M E N T
67
The Department of Nursing at Mass. Eye and Ear provides
quality care to a diverse population of adult and pediatric
patients in the specialties of Ophthalmology and
Otorhinolaryngology.
Patient/family centered care is the framework for nursing
practice. Specialty clinical education and the use of evidence-
based practice, combined with compassion and service
excellence, define the provision of nursing care. Nursing based
on a philosophy of holistic care supports the overall well-being
of the patient.
Shared governance and collaborative practice fosters an
environment that unites the care team with a single goal;
excellence. Through a collegial atmosphere, nurses and
physicians collaborate to ensure high quality outcomes.
During 2013, the Department of Nursing succeeded in
promoting professional practice, maintaining and exceeding
clinical benchmarks and recognizing the extraordinary
contributions made by the nursing staff.
68
As a member of the National
Database of Nursing Quality
Indicator (NDNQI®), the
Department of Nursing has
chosen the RN survey with
Practice Environment Scale (PES)
survey tool for this annual
assessment of the Nursing
Practice Environment.
Using a 1-4 scale, our nurses
assessed the quality of the care
they delivered. Elements of this
assessment included the high
standards of nursing care
expected, competence of their
peers, and the presence of a
clearly defined philosophy of
nursing.
The Nursing Work Environment
The Department of Nursing recognizes that a professional work environment supports
professional practice and improves patient outcomes. The Department of Nursing conducts
an annual nursing work environment survey to assess the professional practice environment
of its nursing staff. This voluntary survey, completed by 97% of the registered nurse
workforce in 2013, a 6% increase from 2012, is designed to assess how the nurses feel
regarding the quality of care they deliver and their nurse-physician relations.
Nursing Practice Environment Scale (PES)
Annual Response Rate
The PES is endorsed by the National Quality Forums and includes a focus on:
• Nursing Foundation for Quality of Care
• Collegial Nurse-Physician Relations
Nursing Foundation for Quality of Care
100
80
60
40
20
02007 2008 2009 2010 2011 2012 2013
Perc
enta
ge
8689 91 91
8691
97
3.0
2.5
2.0
1.5
1.0
02007 2008 2009 2010 2011 2012 2013
2.82 2.86 2.91 2.89 2.912.99 2.98
69
Mass. Eye and Ear’s mission and
vision seeks to promote
excellence in clinical care,
teaching and research. In support
of this, the organization provides
several avenues that foster
collegial nurse-physician
relations. The data reflects a
strong culture of collegiality
among nurses and physicians.
Nurses and physicians practice
Team-Based Simulations to
enhance crisis management of
medical emergencies. Mass. Eye
and Ear has a robust participation
in Schwartz rounds, which are
committed to providing the
opportunity for clinicians to
“re-fuel.” A majority of the
Schwartz rounds have panels
comprised of nurses and
physicians who share the stories
and challenges in providing
compassionate care. This also
contributes to the high level of
collegiality.
Collegial nurse-physician relations are promoted and fostered at Mass. Eye and Ear. The
clinical areas have a co-leadership structure comprised of nursing and physician leaders. This
structure is then adopted through other programs and activities. Through Interdisciplinary
Collaboration, evidence based – best practice is shared resulting in quality improvements.
Nurses along with physician colleagues actively participate in the annual meetings of
national organizations of eye and ear specialties such as the Society of Otorhinolaryngology
and Head and Neck Nurses and the American Society of Ophthalmic Registered Nurses.
Nursing and physician collaboration in research is evident at Mass. Eye and Ear, as noted by
the acceptance for publication of, “Heat and Moisture Exchange Devices for Patients
Undergoing Total Laryngectomy” (ORL Head Neck Nurs. 2014 Winter;32(1):20-3).
Collegial Nurse-Physician Relations
Nurse Quality Indicators (NDNQI®)
3.0
2.5
2.0
1.5
1.0
02007 2008 2009 2010 2011 2012 2013
2.85 2.75 2.84 2.802.95 2.98 2.97
2012, NO
0.26, 26%
2012, YES
0.74, 74%
2013, NO
0.22, 22%
2013, YES
0.78, 78%
2012, NO
0.07, 7%
2012, YES
0.93, 93%
2013, NO
0.06, 6%
2013, YES
0.94, 94%
Nurses felt they had enough time
with their patients
Nurses felt their discharged patients
were adequately prepared
70
The PUP study team consists of
the Adult Unit’s Nursing
Leadership, a Nursing Staff
Champion and a Staff Specialist
from the Center for Quality &
Patient Safety. The team is
guided by the National Quality
Forum’s Nurse Sensitive Care
Outcome Measure®.
The PUP study, initially
conducted quarterly, was
increased to a monthly frequency
at the beginning of the 2013
fiscal year and continues on a
monthly basis.
Hand hygiene is the single most
important way to prevent the
transmission of infection.
Unannounced, randomized spot
checks are performed by
representatives from all
disciplines. Monitoring,
combined with education and
feedback, has resulted in high
levels of employee compliance.
Pressure Ulcer Prevalence Study (PUP)
Hospital acquired pressure ulcers have the potential to cause patient harm. Pain associated
with a pressure ulcer as well as extending the patient’s hospitalization can impact the quality
of their life. The aim of the Nursing Department is to prevent hospital acquired pressure
ulcers through identifying patients at risk to develop pressure ulcer and conducting routine
skin assessments. Monthly Pressure Ulcer Prevalence (PUP) rounds are conducted with a
team of nursing staff members to identify patients at risk and to ensure compliance with
prevention strategies. These prevention strategies are incorporated into the unit’s
purposeful rounding. Through the end of 2013, the Adult Unit has been Pressure Ulcer free
for 306 days.
Hand Hygiene
2.5
2.0
1.5
1.0
0.5
0.0Stage II
or greater2011
Stage III or greater
2011
Stage II or greater
2012
Stage II or greater
2012
Stage II or greater
2013
Stage II or greater
2013
Rat
e pe
r 1,
000
pati
ent
days
Perc
ent
1.75
0
1.56
0
.85
0
100
90
80
70
60
50
40
30
20
10
02011 2012 2013
The health care worker
performs hand hygiene
before each direct patient
contact with soap and water
or alcohol hand gel
The health care worker
performs hand hygiene
before each direct patient
contact with soap and water
or alcohol hand gel
90% Mass. Eye and Ear Benchmark
71
Improving Outcomes through Pediatric Simulation Program: Pediatric Simulated Cardiopulmonary Resuscitation Event Response
The primary goals of the pediatric
simulation program are to
increase team building and
improve clinical skills, response
times and closed-loop
communication.
The Emergency Department
nurses implemented Hourly
Patient Rounding to keep
patients informed, manage
patient’s pain, discuss plan of
care and duration and continually
conduct patient assessments and
need for care.
Success has been found
through accountability and
consistency. The core culture of
rounding is an integrated aspect
of the Emergency Department’s
team approach to quality patient
care.
2011 — Year One
Enhanced knowledge base and skills of nurses, residents, fellows, and attendings
required to effectively manage pediatric codes within the pediatric unit. Empowered staff
through team training and role identification.
2012 — Year Two
Improved closed-loop communication and team leader identification; strengthening
interdisciplinary collaboration.
2013 — Year Three
Expanded simulations to include units outside the pediatric floor that provide pediatric care.
Increasing confidence in staff’s knowledge, skills, and communication.
Emergency Department Elopement
Hardwiring Patient Rounding in the Emergency Department resulted in major
improvements including reduced elopement rates (patients who leave before being seen).
num
ber
of p
atie
nts
50
40
30
20
10
0
Jan-
12
Mar
-12
May
-12
Jul-
12
Sep-
12
Nov
-12
Jan-
13
Mar
-13
May
-13
Jul-
13
Sep-
13
Nov
-13
72
Why I love my job
and Mass. Eye and Ear
Mass. Eye and Ear is my home
away from home. I love this
place. Twenty-three years ago I
sought employment for a night
RN position on the medical/
surgical unit to meet the needs
of my family. Although I
currently work in a very different
job position, I am honored to
work in such a great family
atmosphere. I have seen
enormous growth among staff
throughout the years.
Mass. Eye & Ear provides a
supportive environment that has
encouraged my professional
growth. I love the variety and
daily challenges in my current
operating room nurse position.
I am continually learning and
fascinated with the expertise of
our surgeons. I feel like I make
a difference in what I do and
that I am valued as an employee.
Thanks,
Your proud employee,
Nancy Kotzuba, R.N., M.S.N.
Participation in National Conferences
2013 SOHN 37th Annual Congress Vancouver, BC, CA -
Society of Otorhinolaryngology and Head and Neck Nurses
Hope for Breaking the Silence: Cochlear Implants vs. Auditory Brain Stem Implants
Andria Ledoux, R.N.
“I Am So Dizzy, My Head is Spinning” — Interventions of Meniere’s Disease
Amy Hanby, B.S.N., R.N.
Post-operative Bleeding after a Tonsillectomy or Tonsillectomy and Adenoidectomy as a
Common Complication
Shanna Pagliuca, R.N.
Development of a Transition of Care for Pediatric Patients with Critical Airway Conditions
across Institutions
Kevin Callans, B.S.N., R.N.
Building a Bridge… Finding a Voice
Ann Goulette, R.N., Jane Gallagher, R.N., & Kevin Callans, B.S.N., R.N.
2013 ASORN Annual Meeting - New Orleans, LA – American Society of
Ophthalmic Registered Nurses
Age-related Macular Degeneration “Up close and personal”
Jo Ann Graziano, M.M., R.N. & Mary Jo Graziano, B.S.N., R.N., B.B.A.
Hardwiring Patient Rounding in the Emergency Department at
Massachusetts Eye and Ear
Maureen Martinez, M.S., R.N.
73
DAISY is an acronym for
Diseases Attacking the Immune
System. The Foundation was
formed in November, 1999, by
the family of J. Patrick Barnes
who died at age 33 of
complications of Idiopathic
Thrombocytopenic Purpura (ITP).
The DAISY Foundation
The founders of the DAISY Foundation wanted to say “thank you” to nurses everywhere
by establishing a recognition program to honor the super-human work nurses do for
patients and families every day. Nearly 1,700 healthcare facilities internationally, inpatient
and ambulatory care facilities from urban teaching hospitals to small rural community
facilities participate in the DAISY program. Over 40,000 nurses have been honored as
recipients of the award and nearly 400,000 nurses have been nominated.
In 2013, there were 46 nominations received for the DAISY award. The following
4 recipients were selected anonymously by the Professional Nurse Advisory Committee,
a council comprised of staff nurses.
2013 DAISY Award Recipients:
Cindy Close, R.N. —“We had a 7-year-old boy in the PACU from Shriner’s Burn
hospital. He was in the PACU for 2½ hours without his parents post-op. He really
enjoyed playing games on the iPad. […]Cindy Close, a PACU nurse was very taken by
this young man, his courage and his beautiful smile. She went online and ordered an
iPad for him to enjoy. She did this quietly and does not want any recognition. She truly
felt this act of kindness made her day.”
Pearl Icuspit, R.N. — “I witnessed her caring for a very ill patient in the IMCU. This
patient was anxious and having difficulty getting out secretions. Pearl came to her
side and immediately helped calm her with her soothing voice and gentle touch. Pearl
explained all of her actions to the patient as she was performing them. The patient was
very comfortable when she was done and Pearl was then able to teach the patient how
to take care of her secretions.”
Kristina Orlando, R.N. — “We met Kristina on our first visit to Mass. Eye and Ear. My
son needed an evaluation under sedation of his left eye due to a suspicious mass. A
week later, she made sure to be our nurse for what was the most traumatic experience
of my life. She remembered everything about our family. She requested a social worker
to visit us. She called down to the OR when they were late. She walked the halls with
us. I truly believe she is the reason I made it through that horrible day. When she got
off that day, she called the floor to check on us.”
Deb Trocchi, R.N. — “I went to EW and spoke to Deb asking what to do. Deb said
“Do not worry, let me take care of it.” She went outside and after speaking with the
parents she put the very agitated teenage girl with Down syndrome in a wheelchair
and brought her upstairs to the 12th Floor Retina service herself. This is not the first
time that I asked for Deb’s help at the EW. Kindness, professionalism... She calms down
the patients with her smooth voice and manners; she was definitely destined to be the
great nurse that she is and we are very lucky to have her here at Mass. Eye and Ear.”
Ophthalmology Department Full-time and Affiliate Medical Staff and Practice Locations
Ophthalmology Central Referral and
Appointments Phone: 617-573-3202
Location: Mass. Eye and Ear Infirmary,
243 Charles Street, Boston, MA
Comprehensive Ophthalmology and
Cataract Consultation
617-573-3202
Service Director: Sherleen H. Chen, M.D., F.A.C.S.
Sheila Borboli-Gerogiannis, M.D., F.A.C.S.
Stacey C. Brauner, M.D.
Han-Ying Peggy Chang, M.D.
Matthew F. Gardiner, M.D.
Scott H. Greenstein, M.D., F.A.C.S.
Kristine Lo, M.D.
Christian E. Song, M.D.
Cornea and External Disease
617-573-3938
Service Director: Reza Dana, M.D., M.Sc.,
M.P.H., F.A.R.V.O.
Associate Service Director: James Chodosh,
M.D., M.P.H.
Joseph B. Ciolino, M.D.
Kathryn A. Colby, M.D., Ph.D.
Claes H. Dohlman, M.D., Ph.D.
Pedram Hamrah, M.D.
Deborah S. Jacobs, M.D.
Ula V. Jurkunas, M.D.
Deborah P. Langston, M.D., F.A.C.S.
Samir A. Melki, M.D., Ph.D.
Roberto Pineda, II, M.D.
Peter B. Veldman, M.D.
Emergency Ophthalmology and Eye Trauma
Emergency Department: 617-573-3431
Service Director: Matthew F. Gardiner, M.D.
Maggie B. Hymowitz, M.D.
Eye Trauma: 617-573-3022
Service Director: Alice C. Lorch, M.D. (AY15)
Yewlin Erin Chee, M.D. (AY14)
Glaucoma
617-573-3670
Service Director: Louis R. Pasquale, M.D.,
F.A.R.V.O.
Associate Service Director: Angela V. Turalba, M.D.
Teresa C. Chen, M.D.
Iryna A. Falkenstein, M.D.
Cynthia L. Grosskreutz, M.D., Ph.D.
Ambika S. Hoguet, M.D.
Pallavi Ojha, M.D.
Lucy Q. Shen, M.D.
Brian J. Song, M.D.
Janey L. Wiggs, M.D., Ph.D.
Neuro-Ophthalmology and Adult Strabismus
617-573-3412
Service Director: Joseph F. Rizzo, III, M.D.
Dean M. Cestari, M.D.
John W. Gittinger, M.D.
Simmons Lessell, M.D.
Ocular Tumors
617-573-3202
Han-Ying Peggy Chang, M.D.
Kathryn A. Colby, M.D., Ph.D.
Suzanne K. Freitag, M.D.
Evangelos S. Gragoudas, M.D.
Ivana K. Kim, M.D.
Daniel R. Lefebvre, M.D.
Michael K. Yoon, M.D.
Ophthalmic Pathology
617-573-3319
Service Director: Frederick A. Jakobiec, M.D., D.Sc.
Thaddeus P. Dryja, M.D.
Rebecca Stacy, M.D., Ph.D.
Ophthalmic Plastic Surgery
617-573-5550
Service Director: Suzanne K. Freitag, M.D.
Nahyoung Grace Lee, M.D.
Daniel R. Lefebvre, M.D.
Francis C. Sutula, M.D.
Michael K. Yoon, M.D.
Optometry/Contact Lens
617-573-3185
Service Director: Amy C. Watts, O.D.
Medical Director: James Chodosh, M.D., M.P.H.
Andrew D. Baker, O.D.
Mark M. Bernardo, O.D.
Shannon Bligdon, O.D.
Calliope Galatis, O.D.
Matt Goodman, O.D.
Kevin E. Houston, O.D.
Yan Jiang, O.D., Ph.D.
Charles D. Leahy, O.D., M.S.
Brittney J. Mazza, O.D.
Lotfi B. Merabet, O.D., Ph.D., M.P.H.
Amy Scally, O.D.
Pediatric Ophthalmology and Strabismus
(a collaboration on-site with Children’s Hospital)
617-355-6401
Ophthalmologist-in-Chief, Boston Children’s
Hospital: David G. Hunter, M.D., Ph.D.
Service Director, Mass Eye and Ear: Melanie
A. Kazlas, M.D.
Anna Maria Baglieri, O.D.
Kimberley Chan, O.D.
Linda R. Dagi, M.D.
Alexandra T. Elliot, M.D.
Anne B. Fulton, M.D.
Gena Heidary, M.D., Ph.D.
Suzanne C. Johnston, M.D.
Danielle M. Ledoux, M.D.
Iason Mantagos, M.D.
Kathryn B. Miller, O.D.
Robert A. Petersen, M.D., D.M.Sc.
Ankoor S. Shah, M.D., Ph.D., M.S.
Lois E. H. Smith, M.D., Ph.D.
Deborah K. VanderVeen, M.D.
Carolyn S. Wu, M.D.
Refractive Surgery
617-573-3234
Service Director: Roberto Pineda, II, M.D.
Ula V. Jurkunas, M.D.
Samir A. Melki, M.D., Ph.D.
74
75
Retina Service
617-573-3288
Service Director: Evangelos S. Gragoudas, M.D.
Associate Service Director: Dean Eliott, M.D.
Jason I. Comander, M.D., Ph.D.
Deeba Husain, M.D.
Ivana K. Kim, M.D.
Leo A. Kim, M.D., Ph.D.
John I. Loewenstein, M.D.
Joan W. Miller, M.D., F.A.R.V.O.
Shizuo Mukai, M.D.
Lucia Sobrin, M.D., M.P.H.
Demetrios Vavvas, M.D., Ph.D.
David M. Wu, M.D., Ph.D.
Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.
Retinal Degenerations/
Electroretinography (ERG)
617-573-3621
Service Director: Eric A. Pierce, M.D., Ph.D.
Jason I. Comander, M.D., Ph.D.
John I. Loewenstein, M.D.
Xiang Werdich, M.D.
Uveitis and Immunology
617-573-3591
Service Director: George N. Papaliodis, M.D.
Reza Dana, M.D., M.Sc., M.P.H., F.A.R.V.O.
Ann-Marie Lobo, M.D.
Lucia Sobrin, M.D., M.P.H.
Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.
Vision Rehabilitation
617-573-4177
Service Director: Mary Lou Jackson, M.D.
Calliope Galatis, O.D.
Mass. Eye and Ear/Tele-Retinal Imaging
Program Director: Louis R. Pasquale, M.D.,
F.A.R.V.O.
Leo A. Kim, M.D., Ph.D.
Carolyn E. Kloek, M.D.
Brian J. Song, M.D.
Demetrios Vavvas, M.D., Ph.D.
David M. Wu, M.D., Ph.D.
Location: Mass. Eye and Ear/East Bridgewater,
400 North Bedford Street, East Bridgewater, MA,
Phone: 508-378-2058
Site Director: Angela V. Turalba, M.D.
(Glaucoma)
Daniel R. Lefebvre, M.D.
(Ophthalmic Plastic Surgery)
Louis R. Pasquale, M.D., F.A.R.V.O.
(Glaucoma)
Demetrios Vavvas, M.D., Ph.D. (Retina)
Location: Mass. Eye and Ear/Longwood,
800 Huntington Avenue, Boston, MA,
Phone: 617-936-6100
Site Director: Carolyn E. Kloek, M.D.
(Comprehensive/Cataract)
Mark M. Bernardo, O.D. (Optometry)
Sheila Borboli-Gerogiannis, M.D., F.A.C.S.
(Comprehensive/Cataract, Cornea/
Refractive)
Han-Ying Peggy Chang, M.D.
(Comprehensive, Cornea)
Iryna A. Falkenstein, M.D. (Glaucoma)
Yan Jiang, O.D., Ph.D. (Optometry)
Daniel R. Lefebvre, M.D.
(Ophthalmic Plastic Surgery)
Ann-Marie Lobo, M.D.
(Comprehensive/Cataract, Uveitis)
John I. Loewenstein, M.D. (Retina)
Zhonghui Katie Luo, M.D., Ph.D.
(Comprehensive/Cataract, Cornea/
Refractive)
Lucy Q. Shen, M.D. (Glaucoma)
Brian J. Song, M.D. (Glaucoma)
Peter B. Veldman, M.D. (Cornea)
David M. Wu, M.D., Ph.D. (Retina)
Location: Mass. Eye and Ear/Plainville,
30 Man Mar Drive, Suite 2, Plainville, MA,
Phone: 508-695-9550
Location: Mass. Eye and Ear/Providence,
One Randall Square, Suite 203, Providence,
RI, Phone: 401-453-4600
Southern New England Retina Associates
Site Director: Magdalena Krzystolik, M.D.
(Retina)
Paul B. Greenberg, M.D. (Retina)
Location: Mass. Eye and Ear/Stoneham,
One Montvale Avenue, Stoneham, MA,
Phone: 781-279-4418
Site Director: Matthew F. Gardiner, M.D.
(Comprehensive/Cataract)
Stacey C. Brauner, M.D.
(Comprehensive/Cataract)
Pedram Hamrah, M.D. (Cornea)
Ambika S. Hoguet, M.D. (Glaucoma)
Charles D. Leahy, O.D., M.S. (Optometry)
George N. Papaliodis, M.D.
(Comprehensive/Cataract, Uveitis)
Amy Scally, O.D. (Optometry)
Christian E. Song, M.D. (Comprehensive/
Cataract, Cornea/Refractive)
Angela V. Turalba, M.D. (Glaucoma)
Peter B. Veldman, M.D. (Cornea)
Michael K. Yoon, M.D. (Ophthalmic
Plastic Surgery)
Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.
(Retina)
Location: Mass. Eye and Ear/Retina Consultants,
3 Woodland Road, Stoneham, MA,
Phone: 781-662-5520
Site Director: Deeba Husain, M.D. (Retina)
Jason I. Comander, M.D., Ph.D. (Retina,
Retinal Degenerations)
Leo A. Kim, M.D., Ph.D. (Retina)
Michael Pinnolis, M.D. (Retina)
Location: Mass. Eye and Ear/Waltham,
16 Trapelo Road, Suite 184, Waltham, MA,
Phone: 781-890-1023
Site Director: Jonathan Talamo, M.D.
(Cornea/Refractive)
Shannon Bligdon, O.D. (Optometry)
Kathryn Hatch, M.D. (Cornea/Refractive)
Nahyoung Grace Lee, M.D. (Ophthalmic
Plastic Surgery)
Christian E. Song, M.D. (Comprehensive/
Cataract, Cornea/Refractive)
Karen L. Zar, O.D. (Optometry)
Emergency Otolaryngology
Emergency Department: 617-573-3431
Service Director: H. Gregory Ota, M.D.
General Otolaryngology
Gregory W. Randolph, M.D., F.A.C.S.*,
617-573-4115
Jean M. Bruch, D.M.D., M.D., 617-573-3793
John M. Dobrowski, M.D., 617-573-4104
Allan J. Goldstein, M.D., 617-573-3705
Facial Plastic and Reconstructive Surgery
Tessa A. Hadlock, M.D.*, 617-573-3641
Richard E. Gliklich, M.D., 617-573-4105
Linda N. Lee, M.D., 617-573-4105
Robin W. Lindsay, M.D., 617-573-3778
David A. Shaye, M.D., 617-573-4105
Skin Cancer and Mohs Surgery
Jessica L. Fewkes, M.D., 617-573-3789
Molly Yancovitz, M.D., 617-573-3789
Laser Reconstructive Surgery
Oon Tian Tan, M.D., Ph.D., 617-573-6493
Head and Neck Surgical Oncology
Derrick T. Lin, M.D., F.A.C.S.*, 617-573-3502
Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100
Kevin S. Emerick, M.D., 617-573-4084
Mark A. Varvares, M.D., 617-573-3192
Laryngology
Ramon A. Franco, Jr., M.D.*, 617-573-3958
Jean M. Bruch, D.M.D., M.D., 617-573-3793
Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100
Christopher J. Hartnick, M.D., 617-573-4206
Phillip C. Song, M.D., 617-573-3557
Otology and Neurotology
Michael J. McKenna, M.D.*, 617-573-3672
D. Bradley Welling, M.D., Ph.D.**, 617-573-3632
Ronald K. de Venecia, M.D., Ph.D., 617-573-3715
David H. Jung, M.D., Ph.D., 617-573-3130
Daniel J. Lee, M.D., F.A.C.S., 617-573-3130
Alicia M. Quesnel, M.D., 617-573-3503
Steven D. Rauch, M.D., 617-573-3644
Felipe Santos, M.D., 617-573-3936
Konstantina M. Stankovic, M.D., Ph.D.,
617-573-3972
Vestibular
Steven D. Rauch, M.D.*, 617-573-3644
Richard F. Lewis, M.D., 617-573-3501
Adrian J. Priesol, M.D., 617-573-4148
Gregory T. Whitman, M.D., 617-573-6700
Pediatric Otolaryngology
Christopher J. Hartnick, M.D.*, 617-573-4206
Michael S. Cohen, M.D., 617-573-4250
Donald G. Keamy, Jr., M.D., 617-573-4208
Daniel J. Lee, M.D., F.A.C.S., 617-573-3130
Leila A. Mankarious, M.D., 617-573-4103
Rhinology
Eric H. Holbrook, M.D.*, 617-573-3209
Stacey T. Gray, M.D., 617-573-4188
Benjamin S. Bleier, M.D., 617-573-6966
Nicolas Y. Busaba, M.D., F.A.C.S., 617-573-3558
Thyroid and Parathyroid Endocrine Surgery
Gregory W. Randolph, M.D., F.A.C.S.*,
617-573-4115
Paul M. Konowitz, M.D., 617-573-4084
David J. Lesnik, M.D., 781-279-0971
Derrick T. Lin, M.D., F.A.C.S., 617-573-3502
Suburban Centers
Mass. Eye and Ear, Balance and Vestibular
Center at Braintree Rehabilitation Hospital
617-573-6700
Steven D. Rauch, M.D.*
Gregory T. Whitman, M.D.
Mass. Eye and Ear, Concord
978-369-8780
Michael H. Fattal, M.D.
Jennifer Setlur, M.D.
Michael A. Williams, M.D.
Mass. Eye and Ear, East Bridgewater
Main Line, 508-378-2059
Audiology Services, 508-350-2800
Mandana R. Namaranian, M.D.
Mass. Eye and Ear, Medford
781-874-1965
H. Gregory Ota, M.D.
David M. Bowling, M.D.
Mass. Eye and Ear, Newton-Wellesley
617-630-1699
Mark F. Rounds, M.D.*
Maynard C. Hansen, M.D.
Brian J. Park, M.D.
Kathryn A. Ryan, M.D.
Mass. Eye and Ear, Quincy
617-774-1717
Paul M. Konowitz, M.D., F.A.C.S.*
Peter N. Friedensohn, M.D.
Alex Grilli, M.D.
John B. Lazor, M.D., M.B.A., F.A.C.S.
Mandana R. Namiranian, M.D.
Edward J. Reardon, M.D.
Mass. Eye and Ear, Stoneham
781-279-0971
Michael B. Rho, M.D.*
David J. Lesnik, M.D.
Dukhee Rhee, M.D.
Mass. Eye and Ear, Weymouth-Duxbury
781-337-3424
Cathy D. Chong, M.D.
Amee K. Dharia, M.D.
Hani Z. Ibraham, M.D., F.A.C.S.
David S. Kam, D.M.D., M.D.
Monica S. Lee, M.D.
Otolaryngology Referral Line
617-573-3954
*denotes division leadership
**denotes chair of the department
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Otolaryngology Department Medical Staff