MASSACHUSETTS EYE AND EAR

Transcription

MASSACHUSETTS
EYE
AND
Quality and Outcomes 2014
243 Charles Street
Boston, MA 02114-3096
617-523-7900
617-523-5498 (T.D.D.)
MassEyeAndEar.org
EAR
Contributors
Clinical Leadership in Quality: 2014
Sunil Eappen, M.D.
Assistant Professor of Anaesthesia, Harvard Medical School
Chief Medical Officer, Chief of Anesthesiology,
Massachusetts Eye and Ear
Joan W. Miller, M.D.
Henry Willard Williams Professor and Chair of Ophthalmology,
Harvard Medical School
Chief 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 School
Chief of Otolaryngology, Massachusetts Eye and Ear,
Hugh Curtin, M.D.
Professor of Radiology, Harvard Medical School
Chief of Radiology, Massachusetts Eye and Ear
Teresa C. Chen, M.D.
Associate Professor of Ophthalmology, Harvard Medical School
Chief Quality Officer, Department of Ophthalmology,
Christopher J. Hartnick, M.D., M.S.
Professor of Otology and Laryngology, Harvard Medical School
Vice Chair of Safety and Quality/Clinical Research, Department
of Otolaryngology, Massachusetts Eye and Ear Infirmary
Director, Division of Pediatric Otolaryngology,
Eileen Lowell, R.N., M.M.
Vice President of Patient Care Services, Chief Nursing Officer,
Members of the Mass. Eye
Olumuyiwa Adebona
Evangelos Gragoudas
Corinne Powers
and Ear Quality Steering
Shakhsanam Aliyeva
Stacey Gray
Suzette Profio
John Anderson
Scott Greenstein
Andrew Rabkin
Christopher Andreoli
Tessa Hadlock
Gregory Randolph
Olamide Awosanya
Christopher Halpin
Nikhila Raol
Linda Belkner, R.N.
Sandra Baptista-Pires
Christopher Hartnick
Steven Rauch
Director, Quality and
Linda Belkner
Eric Holbrook
Michael Reinhart
Patient Safety
Jean Bibeau
David Hunter
Aaron Remenschneider
Sheila Borboli-Gerogiannis
Mary-Lou Jackson
Mike Ricci
Stacey Brauner
Maryann Jerrier
Debbie Rich
Charlene Callahan
Grace Jonak
Joseph Rizzo
Dean Cestari
Justin Kanoff
Debra Rogers
Kenneth Chang
Dipti Karmani
Barbara Scully
Michael Ricci
Peggy Chang
Melanie Kazlas
Alexandra Selivanova
Chief Information Officer
Wendy Chao
Ivana Kim
Jennifer Street
Yewlin Chee
Leo Kim
Debra Trocchi
Sherleen Chen
Carolyn Kloek
Angela Turalba
Teresa Chen
Elliott Kozin
Joseph Vadakekalam
James Chodosh
Sharon Kujawa
Peter Veldman
Janet Cohan
Anne Marie Lane
Rhonda Walcott-Harris
Louise Collins
Mary Leach
Suzanne Ward
Lisa Cowan
Daniel Lee
Rachel Wasserstrom
Laura D’Amico
Daniel Lefebvre
Amy Watts
Linda Dagi
Kathleen Lennon
Bradley Welling
Reza Dana
Patricia Li
Julia Wong
Mindy Davis
Derrick Lin
Janet Yedziniak
Suzanne Day
Robin Lindsay
Lucy Young
Sandy DeCelle
Ann-Marie Lobo
Peter Delisle
John Loewenstein
Daniel Deschler
Katie Luo
Medical Illustrations by:
Gillian Diercks
Joe Marshall
Laurel Cook Lhowe
April Dobbs
Maureen Martinez
Claes Dohlman
Kathy McCormack
Graphic Design by:
Anne Marie Donnelly
Fran McDonald
Marc Harpin,
Dean Eliott
Michael McKenna
Rhumba Design
Tobias Elze
Lisa McLellan
Kevin Emerick
Ralph Metson
Kimberly Farwell
Joan Miller
Tanya Fedyshyn
John Miller
John Fernandez
Alfred Minincleri
Cherie Florio
Nicolas Moretti
Ramon Franco
Anne Murphy
Martha Fraser
Garyfallia Pagonis
Suzanne Freitag
George Papaliodis
Sandra Gallagher
Louis Pasquale
Matthew Gardiner
Eric Pierce
Amanda Goggin
Roberto Pineda
Committee also include:
Mary Kennedy
Risk Manager
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
Please note that information
success reflected in the information you’ll see here. We continually evolve to
contained in this book focuses
serve our patient population better, which is made up largely of people seen on
primarily on the work of
an outpatient basis. We have only 41 inpatient beds, but serve almost 27,000
the full-time staff at Mass. Eye
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,
and Ear’s main Boston campus,
unless otherwise stated.
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
About Massachusetts Eye and Ear
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
Clinical Locations
Boston — Main Campus
subspecialty care and serves as a referral center for inpatient and outpatient
Boston — Longwood
medical and surgical care.
Boston — Joslin
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 —
Braintree
Concord
Duxbury
East Bridgewater
Medford
locally, nationally and beyond our borders — to increase our reach and make our
Milton
expertise, services and resources available to all who need them.
Newton
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
Plainville
Providence
Quincy
Stoneham — Montvale Avenue
Stoneham — Woodland Road
otolaryngology resources available.
Waltham
Weymouth
2013 Hospital Statistics
(Jan. 1 – Dec. 31, 2013)
Patient Volume
For more information, visit
Outpatient services..............................................................................................388,551
MassEyeAndEar.org/Locations
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
2
SURGERY
OVERVIEW
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.
3
Mass. Eye and Ear Surgical Volume
20,000
Mass. Eye and Ear has 21
operating rooms between the
Number of operating room procedures
Main Operating Room and the
6th floor Surgical Suites at the
15,000
main campus and 4 operating
rooms at the Longwood Site
on Huntington Avenue.
10,000
Currently we only care for
adult ambulatory patients at
MEE-Longwood, but we expect
5,000
to have initiated pediatric care
in January 2015 and anticipate
0
offering otolaryngology and
2008
2009
2010
2011
2012
audiology services in the
2013
summer of 2015. Regardless
Longwood
6th Floor Surgical Suite
Main Operating Room
Total
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.
Ophthalmology and Otolaryngology Surgical Volume
12,000
The ophthalmology and
otolaryngology surgical
10,000
volumes have been split fairly
evenly over the past 5 years.
This year’s difference was
8,000
spurred on by the growth of
ophthalmology volume at the
6,000
Longwood Site.
4,000
2,000
0
2008
2009
2010
Ophthalmology
4
2011
2012
Otolaryngology
2013
Adult and Pediatric Volume
16,000
Mass. Eye and Ear cares for the
most pediatric otolaryngologic
14,000
patients in the area and for
more pediatric surgical patients
12,000
than anyone other than Boston
10,000
Children’s Hospital. Pediatric
surgical volume has remained
8,000
approximately one-third of
6,000
Mass. Eye and Ear’s overall
volume for the last few years.
4,000
2,000
0
2008
2009
2010
Adult
2011
2012
2013
Pediatric
Postoperative Nausea and Vomiting (PONV)
in the Post Anesthesia Care Unit (PACU)
10.0
9.0
8.0
Percentage
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
PONV in
PACU
Adult
Delay in
discharge
Pediatric
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).
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
Treatment Success of Pain in the PACU
100
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.)
80
Percentage
60
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
40
as comfortable as possible.
Often, in the recovery room,
the patient may need more
20
analgesics prior to leaving.
Our goal is to ensure that every
0
Pain
treated
Pain score < 3
on discharge
Adult
Pediatric
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 selfreport 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-ArmsCrying-Comfortable) scale
that attributes behavioral
characteristics to a 10-point
pain scale. These are the scores
reported above for pediatric
patients.
6
OPHTHALMOLOGY
DEPARTMENT
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 patientcentered core values focus on delivering the highest quality of care
through education, innovation and service excellence.
7
Department of Ophthalmology
Massachusetts Eye and Ear, Harvard Medical School
We Are:
Academic Affiliations
• 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:
Harvard Medical School
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
Cornea
Veterans Affairs Maine
Healthcare System
Diabetic Eye Disease
Cambridge Health Alliance
Age-related Macular Degeneration
Glaucoma
Mobility Enhancement & Vision Rehabilitation
Ocular Oncology
Aravind Eye Hospital, India
Eye and ENT Hospital of Fudan
University, Shanghai, China
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 NeuroOphthalmology 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
• Brigham and Women’s Hospital (BWH)
-M
ass. Eye and Ear provides comprehensive and subspecialty care and
inpatient consultations to BWH patients, including 24/7 emergency eye care
and trauma coverage.
-B
WH 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
-M
ass. Eye and Ear ophthalmologists provide subspecialty care in glaucoma
and cornea disease at Boston Children’s Hospital.
-C
hildren’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.
For more information about
the Mass. Eye and Ear Quality
Program or the Department
of Ophthalmology, please
• Our dedicated Eye Emergency Department is available 24/7.
visit our website at
• The Morse Laser Center provides advanced laser procedures using state-of-the-
www.MassEyeAndEar.org.
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
Eye Anatomy
sclera
retina
Data reported for 2010,
2011, 2012, and 2013
represent calendar years.
The 2009 data represent
iris
macula
pupil
12-month results as noted.
vitreous
cornea
optic nerve
lens
Emergency Department:
Ophthalmology Emergency Visits
1,800
This bar graph shows the
number of ophthalmology
patients seen monthly by the
1,500
Mass. Eye and Ear Emergency
Department during the past
Number of visits
1,200
five calendar years. Throughout
this time, the Emergency
900
Department maintained a
high volume of ophthalmic
emergency visits, with an
600
average of 1,060 patients per
month in 2009, 1,050 in 2010,
300
1,091 in 2011, 1,304 in 2012
and 1,266 in 2013. Patient
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
2009 (N = 12,717)
10
2010 (N = 12,603)
2011 (N = 13,086)
2012 (N = 15,650)
2013 (N = 15,189)
volume generally increases
in the summer.
Ophthalmology Visit Times
5
National Average 4.12 Hours
4
Massachusetts Average 4.06 Hours
3.1
Hours
3
2.3
2.1
2.3
2.5
2
1
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 ophthalmologist. 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.
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.
0
2009 (N = 12,717)*
2010 (N = 12,603)
2011 (N = 13,086)
2012 (N = 15,650)
2013 (N = 15,189)
*October 2008 – September 2009
Ophthalmology “Left Without Being Seen” (LWBS) Rate
10
9
8
Percentage
7
6
5
1.7% to 4.4% 1-3
4
3
2
1
1.1%
1.1%
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
The Mass. Eye and Ear
Emergency Department
has a lower LWBS rate
when compared to
national benchmarks.
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.
2012 (N = 15,650)
2013 (N = 15,189)
National Benchmark 11
Eye Trauma Surgery
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.
Eye Trauma Surgery:
Postoperative Median Vision
20/15
20/20
20/25
20/30
20/40
Best-Corrected Visual Acuity
20/40
20/50
20/60
20/60
20/70
20/70
20/80
20/100
20/100
20/200
20/400
Count
Fingers
Hand
Motions
Count
Fingers
Hand
Motions
Light
Perception
Light
Perception
No Light
Perception
Hand
Motions
2010
(N = 58)
2011
(N = 59)
Preoperative Vision
Postoperative Vision
12
2012
(N = 63)
2013
(N = 68)
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.
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 presentation 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
Eye Trauma Surgery:
Rates of Endophthalmitis After Open-Globe Repair
Percentage of endophthalmitis
25
20
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 openglobe 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
2.6% to 17%
15
10
U.S. Rate 6.9%
5
0
0% 0% 0% 0%
0%
2009 (N = 95)
2010 (N = 96)
2011 (N = 98)
2012 (N = 122)
2013 (N = 118)
International Benchmark
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
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.
Eye Trauma Surgery:
Time to Surgical Repair for Open-Globe Injuries
99.2%
100.0%
99.2%
100
Percentage
80
76.3%
69.7%
66.0%
60
40
20
0
< 12 hours
< 24 hours
Time to Operating Room
2009 (N = 95)
2012 (N = 122)
2013 (N = 118)
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.
13
Cataract Surgery
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,
normal lens
continued management of a
cataract
or cloudy
lens
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.
Cataract Surgery:
Achieving Target Refraction (Spherical Equivalent)
71% to 94%1-4
100
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.
90
80
Percentage
70
60
50
40
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
30
20
10
0
< -2
-2 to < -1
-1 to +1
> +1 to +2
Dioptric difference from target refraction
2009 (N = 974)*
2010 (N = 1,285)
2011 (N = 1,250)
2012 (N = 1,437)
2013 (N = 1,664)
*July 2008-June 2009
14
> +2
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): 19351939. 2Cole Eye Institute. Outcomes 2012.
3
Lum 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.
consistently met or exceeded
international benchmarks for
successful cataract surgery.
Cataract Surgery:
Intraoperative Complication Rates
10
Comprehensive Ophthalmology
Percentage of intraoperative complications
9
Service has excellent
8
intraoperative complication
7
rates compared to international
benchmarks.
6
0.3% to 4.4%
5
4
3
2
1
0
0% to 0.9%
0.2%
1.7%
1.6%
0.1% to 1.2%
0.3%
0.3%
Descemet’s tear
0% to 1.7%
PC tear and/or
vitreous loss
0.2%
Nuclear fragment/
dropped fragment/
retained lens fragment
0.2%
0.5%
Zonular dialysis
2012 (N = 1,464)
2013 (N = 1,719)
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.
5
McKellar 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.
15
Retina Surgery:
Retinal Detachment and Retinal Detachment Repair
scleral buckle
The Retina Service at Mass.
Eye and Ear is one of the
vitreous
detachment
largest subspecialty groups
of its kind in the country. Our
clinicians are highly skilled at
diagnosing and treating a full
range of ocular conditions,
subretinal
fluid
retinal
detachment
retinal
tear
including macular degeneration,
diabetic retinopathy, retinal
detachments, ocular tumors,
intraocular infections, and
severe ocular injuries.
Retina Surgery:
Single Surgery Success Rate for
Primary Rhegmatogenous Retinal Detachment
59.4% to 95%1-5
100
90
80.0%
Percentage of retinas attached
80
76.4%
70
60
50
40
30
20
10
0
2012 (N = 173)
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).
2013 (N = 220)
References: 1Soni C et al. Surgical management of rhegmatogenous retinal detachment:
a meta-analysis of randomized controlled trials. Ophthalmology 2013; 120: 1440-1447.
Feltgen 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.
2
16
Retina Surgery:
Final Retinal Reattachment Rate for
Primary Rhegmatogenous Retinal Detachment
97% to 100%1-5
100
95.6%
97.4%
98.4%
99.4%
99.5%
90
Percentage of retinas reattached
80
70
60
50
40
30
20
10
0
2009 (N = 160)*
2010 (N = 78)
2011 (N = 189)
2012 (N = 173)
2013 (N = 220)
*March 2008-February 2009
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.
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
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.
Macular Hole Surgery:
Single Surgery Success Rate at Three Months
89.8% to 93.0%1-3
100
93.1% 93.9%
Percentage of closed macular holes
90
80
70
60
50
40
30
20
10
0
2012 (N = 29)
2013 (N = 33)
National Benchmark
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.
17
Retina Surgery
(left) Photograph of
endophthalmitis
Photo courtesy of Lucy H. Young,
M.D., Ph.D., F.A.C.S.
Retina Surgery:
Rates of Endophthalmitis After Intravitreal Injection
10
9
Percentage of endophthalmitis
8
7
6
5
4
3
0.02% to 1.9%1
2
1
0
0.00% 0.05% 0.00% 0.03% 0.00%
2009 (N = 1,989)
2010 (N = 2,190)
2011 (N = 3,319)
2012 (N = 6,094)
2013 (N = 7,458)
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): 15811583. 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. Metaanalysis of infectious endophthalmitis after intravitreal
injection of anti-vascular endothelial growth factor agents.
Ophthalmic Surg Lasers Imaging Retina 2014; 45:143-149.
Acute endophthalmitis is a
rare potential complication of
intravitreal injections. Mass.
Eye and Ear has excellent
intravitreal injection infection
rates compared to international
benchmarks.
Retina Surgery:
Ophthalmic Oncology
(left) Localization of
choroidal melanoma with
transillumination. Tantalum
rings outline the tumor.
Photo courtesy of Evangelos S.
Gragoudas, M.D.
Retina Surgery:
Ophthalmic Oncology –
Globe Perforation Rate from Surgery
10
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.
9
Percentage of globe perforations
8
7
6
5
4
3
2
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
1
0
The Ophthalmic Oncology
0%
0%
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.
first proton beam irradiation
treatment was administered to a
Mass. Eye and Ear patient with
2012 (N = 99)
2013 (N = 101)
intraocular malignant melanoma.
19
Glaucoma Surgery
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
PRESSURE
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—
Glaucoma Surgery:
Trabeculectomy and Tube Shunt Infection Rates
25
Percentage of infections
20
15
10
0.12% to 8.33% 1
5
0%
0
0%
0%
0%
2010 (N = 245)
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
2011 (N = 270)
2012 (N = 323)
2013 (N = 307)
International Benchmark 20
Reference: 1Ang GS et al. Postoperative infection in penetrating versus nonpenetrating glaucoma surgery. Br J Ophthalmol 2010; 94(12): 1571-1576.
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.
Trabeculectomy and Glaucoma Implant Surgery:
Intraoperative Complications
10
Percentage of intraoperative complications
Glaucoma Consultation
1% to 8%
Service continues to maintain
8
very favorable intraoperative
complication rates compared
6
4
to international benchmarks.
0% to 3%
1.1% to 3%
2
0.7%
0
Conjunctival
tear/buttonhole
Hyphema
Scleral flap
trauma
1%
Vitreous loss/
prolapse
0% to 1%
Suprachoroidal
hemorrhage
2007-2009 (N = 308)* 2010 (N = 245)
2011 (N = 270) 2012 (N = 323)
2013 (N = 217) International Benchmark 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.
International benchmarks:1-4
Mass. Eye and Ear 2013 complication rates:
Conjunctival tear/buttonhole: 1.1% - 3.0%
Conjunctival tear/buttonhole: 1.4%
Hyphema: 1.0% - 8.0%
Hyphema: 0%
Scleral flap trauma: 0.7%
Scleral flap trauma: 0%
Vitreous loss (vitreous prolapse): 1.0%
Vitreous loss (vitreous prolapse): 0%
Suprachoroidal hemorrhage: 0% - 1.0%
Suprachoroidal hemorrhage: 0%
Scleral perforation: 0% - 3.0%
Scleral perforation: 0%
The 217 cases evaluated included:
79 trabeculectomies without scarring
14 trabeculectomies with previous scarring
105 primary tube surgeries
19 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.
21
Glaucoma Laser Surgery:
Postoperative Intraocular Pressure (IOP) Spikes
40
Preoperative and postoperative
0% to 35%
intraocular pressure (IOP)
Percentage of IOP spikes
0% to 31.7%
measurements were taken
30
using the Tono-Pen (Reichert,
Buffalo, NY) prior to the laser
20
procedure and within one
7% to 10.3%
hour of the conclusion of
5.7% to 13%
0% to 9.8%
10
0%
0.02% to 4%
the laser procedure. For this
analysis, if multiple pressure
3%
readings were taken, the
0
average pressure reading was
Laser peripheral
iridotomy
Capsulotomy
Laser
Trabeculoplasty
(ALT/SLT)
Overall
Laser peripheral
iridotomy
≥5 mm Hg
2012 (N = 556)
Capsulotomy
Laser
Trabeculoplasty
(ALT/SLT)
Overall
IOP difference (postoperative
≥10 mm Hg
2013 (N = 587)
used when calculating the
minus preoperative). All
measurements were taken
by a certified ophthalmic
technician. All patients received
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
Mass. Eye
and Ear
International1-8
≥10 mm Hg
Mass. Eye
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.
22
either brimonidine 0.1% or
0.15% or apraclonidine 0.5%
before the laser procedure and
prednisolone 1% after the
procedure.
Glaucoma Surgery:
Mitomycin C Trabeculectomy Reoperation Rates
at One Month and Six Months
10
9
Percentage of reoperations
8
7
6
5
4.3%
4
3
2.2%
2
1
0
One Month Postoperative (N = 93)
Six Months Postoperative (N = 92)
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 sixmonth 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.
In summary, the Mass. Eye
and Ear Glaucoma Consultation
Service achieves excellent
surgical success with
trabeculectomy, and
reoperation rates are low.
23
Refractive Surgery (Laser Vision Correction)
1.
2.
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),
3.
4.
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).
Refractive Surgery — LASIK for Myopia:
70% to 83%1-2
Percentage within 0.5 diopters of target refraction
100
90.1%
86.9% 86.9% 88.1% 89.3%
90
80
70
60
50
40
30
20
10
0
2009 (N = 289)*
2010 (N = 252)
2011 (N = 260)
2012 (N = 271)
2013 (N = 212)
24
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.
During the 2013 calendar
year, 248 of the 263 eyes
that had LASIK surgery had
sufficient follow-up data for
analysis. Sufficient followup 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).
Refractive Surgery — LASIK for Different Degrees of Myopia:
100
90
97.3
91.5
90.4
87.8
86.1
The Mass. Eye and Ear Cornea
96.8
95.0
91.2
85.4
and Refractive Surgery Service
87.9
82.1
80
81.3
81.3
80.0
75.9
continues to maintain a high
overall success rate for LASIK
surgery for myopia.
70
60
50
40
30
20
10
0
Low Myopia
less than 3 diopters of sphere
2009 (N = 289)*
Moderate Myopia
3 to <7 diopters of sphere
2010 (N = 252) 2011 (N = 260)
High Myopia
7 to 10 diopters of sphere
2012 (N = 271)
2013 (N = 212)
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.
25
Refractive Surgery — LASIK for Hyperopia:
66.7% to 91%1-3
100
85.0%
90
79.3%
80
77.8%
80.6%
68.0%
70
60
50
40
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
Mass. Eye and Ear Cornea
has consistently met the
international benchmarks
for successful LASIK surgery
for hyperopia.
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.
2
Keir 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.
30
20
10
0
2009 (N = 40)*
2010 (N = 29)
2011 (N = 25)
2012 (N = 36)
2013 (N = 36)
Refractive Surgery — LASIK:
Enhancement/Retreatment Rates at Six Months Follow-up
50
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
45
LASIK retreatments/enhancements
40
35
3.8% to 29.4% 1-3
30
25
20
15
10
7.4%
5
6.8%
2.7%
5.2%
0
2010 (N = 296) 2011 (N = 285)
2012 (N = 307) 2013 (N = 248) International Benchmark 26
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.
2
Yuen 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.
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.
Cornea Surgery:
Keratoprosthesis (KPro)
(left) Photograph of
keratoprosthesis (KPro)
Photo courtesy of
Claes Dohlman, M.D., Ph.D.
Cornea Surgery:
Surgical Indications for Keratoprosthesis (KPro)
Mucus Membrane
Pemphigoid
3.4%
Failed Graft
62.1%
Perforated Cornea
3.4%
Corneal
Neovascularization
10.3%
Aniridic
Keratopathy
20.7%
N = 29
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.
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 worldwide, 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
27
Cornea Surgery:
Visual Outcomes of Keratoprosthesis (KPro)
56% to 89%1-3
100
90
84%
76%
80
66.7%
Percentage
70
60
50
40
30
For the past three years, the
Mass. Eye and Ear Cornea
has consistently met national
benchmarks for visual outcomes
following keratoprosthesis
(KPro) surgery.
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.
3
Greiner 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.
20
10
0
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.
20/200
or better
2011 (N = 27) 2012 (N = 25)
2013 (N = 29)
National Benchmark
Cornea Surgery:
Keratoprosthesis (KPro) Retention Rates
90.5% to 95%1-2
100%
100%
100
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
90
80
70
Percentage
100%
60
50
40
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.
30
20
10
0
2011 (N = 27) 2012 (N = 25)
2013 (N = 29)
National Benchmark
28
KPro retention rates at three
months were 100% in 2011,
2012, and 2013.
Cornea Surgery:
Penetrating Keratoplasty
(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.
Cornea Surgery:
Distribution of Full-Thickness and
Partial-Thickness Keratoplasty
Descemet’s
Stripping Endothelial
Keratoplasty (DSEK)
58.5%
N = 183
Penetrating
Keratoplasty (PK)
33.3%
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 partialthickness procedures: 107 Descemet’s
stripping endothelial keratoplasties
(DSEK) and 15 deep anterior lamellar
keratoplasties (DALK).
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.
Deep Anterior
Lamellar Keratoplasty
(DALK)
8.2%
29
Cornea Surgery:
Surgical Indications for Penetrating Keratoplasty (PK)
Neurotrophic
Keratopathy
1.7%
Corneal Dystrophy
1.7%
Corneal Edema
3.5%
Bullous
Keratopathy
5.2%
Failed
Corneal
Graft
41.4%
Fuchs’
Dystrophy
6.9%
Keratoconus
15.5%
Corneal Scar
24.1%
N = 58
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%).
In 2013, the most common
indications for elective fullthickness keratoplasties (PKs)
at Mass. Eye and Ear were
failed corneal graft (41.4%),
corneal scar (24.1%), and
keratoconus (15.5%).
Cornea Surgery:
Clear Corneal Grafts after Penetrating Keratoplasty (PK)
Surgery at Three Months Follow-up
92.5% to 95%1-2
Percentage of grafts clear for elective PK
100
96.8%
93.0% 92.8%
98.3% 98.3%
90
80
70
60
50
40
30
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 followup 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.
20
10
0
2009 (N = 126)*
2010 (N = 71)
2011 (N = 69)
2012 (N = 60)
2013 (N = 58)
*July 2008-July 2009
30
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.
Mass. Eye and Ear PK surgery
success rates have consistently
met or exceeded international
benchmarks.1-2
Oculoplastic Surgery:
Dacryocystorhinostomy (DCR) Lacrimal Bypass Surgery
Dacryocystorhinostomy (DCR)
is a surgery that aims to
Lacrimal gland
improve tear drainage from the
Canaliculus
lacrimal sac to the nose.
Lacrimal sac
DCR ostium site
Nasolacrimal duct
Reoperation Rate for External Dacryocystorhinostomy
(Ex-DCR) Surgery at Six Months Follow-up
Reoperation rate after external DCR surgery (%)
25
20
15
7.8% to 12.5%1-3
10
5
1.8%
0
0.0%
2012 (N = 70)
2013 (N = 56)
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 preexisting 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
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.
References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with
nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003; 110:78-84.
2
Karim R et al. A comparison of external and endoscopic dacryocystorhinostomy
for acquired nasolacrimal duct obstruction. Clinical Ophthalmology 2011; 5:979989. 3Ben Simon GJ et al. External versus endoscopic dacryocystorhinostomy for
acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology
2005; 112:1463-1468.
31
Reoperation Rate for Endoscopic Dacryocystorhinostomy
(En-DCR) Surgery at Six Months Follow-up
Reoperation rate after endoscopic DCR surgery (%)
25
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
20
15
2% to 11%1-4
10
5.6%
5
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.
3
Moore 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.
0
2013 (N = 18)
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.
Reoperation Rate for Lid Surgeries at Six Months Follow-up
Reoperation rate after lid surgery (%)
25
20
15
2.6% to 8.7%1-2
10
5
2.9%
2.6%
3.1%
1.7%
0
2009 (N = 343)*
2011 (N = 416)
2012 (N = 467)
2013 (N = 574)
*March 2008-February 2009
32
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.
Ophthalmic Plastic Surgery
Service continues to have one
of the lowest reoperation rates
for eyelid surgeries compared
to international benchmarks.
Pediatric and Adult Strabismus Surgery
esotropia (ET)
exotropia (XT)
Recession and resection
procedures are most commonly
performed for horizontal
misalignment. Other surgeries
less frequently performed
include loop myopexies and
transpositions.
resection surgery
muscle
advanced
recession surgery
muscle
recessed
part of muscle
resected
after 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.
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.
Reference: 1Ehrenberg M et al. Goal-determined metrics to assess outcomes of esotropia surgery. JAAPOS 2014;18:211-16.
33
Outcomes Criteria
1. Goal—Binocular Potential for Esotropia (ET)
Subjective
Distance angle1 Indications for strabismus
Near angle
Excellent
ET≤10∆ or XT≤5∆
No XT, any ET
Good
10∆< ET≤15∆ or
5∆<XT ≤10∆
X(T)≤10∆ any ET
Poor
Recommend reoperation (horizontal)
ET>15 or XT>10
Poor
Near angle
Near stereo-acuity <2 octaves
worsened from pre-op and
not diminished to nil2
10∆≤XT<15∆
or 6≤ET≤10∆
10≤XT<15∆
or 6≤ET≤10∆
Recommend reoperation
(horizontal)
XT>
_15∆
or ET>
>10∆
XT>
_15∆
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
(horizontal)
ET or XT>15∆
1. O
rder 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
34
(reconstructive), treatment of
(torticollis).
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
of normal eye contact
of anomalous head posture
Good
of binocular vision, restitution
double vision, or reduction
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
surgery included restoration
Outcomes Criteria
4. Goal—Resolution of Diplopia (ET or XT)
Subjective
Excellent
No diplopia in primary1
Good2,3
Diplopia controlled with prism
Although there were no
surgeries performed for
torticollis in calendar year
2013, there were four cases
in calendar year 2012.
PoorRecommend 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 primary
2. Pre-existing vertical alignment controlled with prism does not affect result if no increase
3. New vertical alignment requiring prism cannot exceed “good” outcome
5. Goal—Reduction of Torticollis (ET or XT)
Subjective1Torticollis2
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)
35
Exotropia Outcomes Stratified by Goal
100
10.3
21.4
80
12.5
13.3
3.3
14.1
11.5
11.5
7.1
60
Percentage
27.6
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.
17.5
9.3
24.1
100.0
40
83.3
75.6
71.4
87.5
77.0
73.2
48.3
20
0
2012
2013
(N = 28) (N = 29)
Binocular
Potential
2012
2013
(N = 78) (N = 60)
2012
2013
(N = 14) (N = 8)
2012
2013
(N = 122) (N = 97)
Reconstructive
Diplopia
Overall
%Excellent
%Good
%Poor
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.
Exotropia Outcomes Stratified by Risk Factors
100
5.0
20.0
33.3
Percentage
80
10.0
23.5
15.8
4.0
4.0
9.7
20.0
33.3
8.0
33.3
2.9
18.4
14.0
10.6
24.0
9.7
14.0
12.8
6.0
16.7
92.0
85.0
40
72.0
65.8
100.0
100.0
risk factors.
100.0
80.6
77.1
72.0
76.6
66.7
66.7
47.1
70.0
50.0
20
0
2013
2013
2013
2013
2012
2012
2012
2012
2013
2013
2013
2013
2012
2012
2012
2012
Risk
Risk
No Risk
No Risk
No Risk
Risk
Risk
No Risk
No Risk
Risk
Risk
No Risk
Risk
No Risk
No Risk
Risk
Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors
(N = 25) (N = 3) (N = 17) (N = 12) (N = 40) (N = 38) (N = 25) (N = 35) (N = 5) (N = 9) (N = 5) (N = 3) (N = 72) (N = 50) (N = 47) (N = 50)
Binocular Potential
%Excellent
Reconstructive
%Good
Diplopia
Overall
%Poor
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.
36
strabismus surgery in 2013,
50 patients had associated
29.4
60
exotropia who underwent
Esotropia Outcomes Stratified by Goal
100
9.7
23.9
80
9.7
4.8
9.5
13.3
20.0
4.8
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.
8.9
19.0
6.2
10.0
8.5
9.9
Percentage
60
40
66.2
95.2
85.7
80.6
80.0
76.7
84.9
72.5
20
0
2012
2013
(N = 71) (N = 62)
Binocular
Potential
2012
2013
(N = 60) (N = 63)
2012
2013
(N = 20) (N = 21)
2012
2013
(N = 153) (N = 146)
Reconstructive
Diplopia
Overall
%Excellent
%Good
%Poor
Of 146 patients with esotropia,
62 underwent surgery to
restore binocular vision, 63
for reconstructive goals, and
21 to resolve diplopia.
Esotropia Outcomes Stratified by Risk Factors
100
8.2
23.1
26.3
10.2
80
7.7
9.6
Percentage
15.4
12.9
9.7
13.8
10.3
12.5
7.7
2.6
8.3
23.5
18.6
19.4
9.3
7.5
8.3
8.5
9.4
8.5
3.1
64 patients had associated
100.0
81.6
67.3
esotropia who underwent
strabismus surgery in 2013,
10.5
60
40
76.9
77.4
75.9
79.2
63.2
risk factors.
100.0
91.7
89.7
76.5
72.1
73.1
82.9
87.5
20
0
2012
2012
2013
2013
2012
2012
2013
2013
2012
2012
2013
2013
2012
2012
2013
2013
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors
(N = 52) (N = 19) (N = 49) (N = 13) (N = 31) (N = 29) (N = 24) (N = 39) (N = 3) (N = 17) (N = 9) (N = 12) (N = 86) (N = 67) (N = 82) (N = 64)
Binocular Potential
%Excellent
Reconstructive
%Good
Diplopia
Overall
%Poor
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.
37
Scleral Perforation During Strabismus Surgery
Rate of Scleral Perforation (%)
10
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.
8
6
4
2
0.54%
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.
0
2013 (N = 367)
Infection Within 30 days After Surgery
Postoperative infection rate (%)
10
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.
8
6
4
2
0.9%
0
Strabismus
Surgery
(N = 350)
38
0.0%
0.0%
Pediatric
Cataract
Surgery
(N = 83)
Ptosis
Surgery
(N = 40)
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.
Neuro-Ophthalmology:
Imaging Study Results to Patients
During calendar year 2013, the Mass. Eye and Ear Neuro-Ophthalmology Service ordered
For the past two years, the
407 outpatient neuroimaging scans (e.g., MRI, CT scans, etc.). Thirty-four of these scans
Mass. Eye and Ear Neuro-
were excluded from analysis because they were cancelled (21) or performed at outside
Ophthalmology Service has
hospitals (13). This left a total of 373 scans for the current analysis. Follow-up rates reflect
maintained favorable rates of
the length of time from when the scan was performed to when the ordering physician
follow-up for results of
was able to successfully reach the patient (not necessarily the first call to the patient).
outpatient imaging studies
compared to published
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;
guidelines and international
151 (40.5%) within two business days; 309 (82.8%) within seven calendar days; and
benchmarks.
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 followup 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
Of the 373 scans that were
90.8%
90
ordered by a physician in the
82.8%
Neuro-Ophthalmology Service
80
and also completed at Mass.
Percentage
70
56.4%
60
50
(94.9%) had documentation of
*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%).
40.5%
27.3%
20
10
0
Eye and Ear in 2013, 354 scans
2013 (N = 373)
when the patient was notified
41.7%
40
30
2012 (N = 360)*
Within 24
business hours
Within 48
business hours
Within 7
calendar days
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
39
Neuro-Ophthalmology Service:
Patient Satisfaction Survey
Quality of Service (%)
100
80
When asked to rate the overall quality of
service, 290 patients (98.3%) responded
that the quality of service in the NeuroOphthalmology Clinic was either “Excellent”
or “Very Good.” The response options are
indicated in the graph on the left.
82.4%
60
40
15.9%
20
On January 2, 2013, the
Mass. Eye and Ear NeuroOphthalmology Service
launched a patient satisfaction
survey to prospectively
evaluate the patient experience
1.7%
0
in the Neuro-Ophthalmology
0.0%
Clinic. The voluntary survey
Excellent (N = 243) was completed by 295 patients
Very Good (N = 47)
during the 2013 calendar year.
Good (N = 5) Substandard (N = 0)
The results summarized here
N = 295
reflect the responses of 165
new patients and 130
established patients, 55.9%
Clarity of Instructions (%)
100
80
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.”
65.8%
60
40
21.4%
20
11.2%
0
Prior to every appointment in
the Neuro-Ophthalmology
Clinic, patients are given
detailed information and
1.5%
instructions to better prepare
them for the visit. These
Excellent (N = 194) instructions explain to the
Very Good (N = 63)
patient that Neuro-
and 44.1%, respectively.
Ophthalmology visits are much
N = 295
longer than most doctor visits,
that it is important to bring past
Friendliness of Physicians (%)
imaging studies (i.e., MRI or CT
100
Two hundred ninety patients (98.3%) rated
the friendliness and courteousness of the
Neuro-Ophthalmology physicians as either
“Excellent” or “Very Good.”
87.1%
80
60
11.2%
0
blurry for a few hours after the
eye exam is completed. These
inform the patients.
1.7%
0.0%
Excellent (N = 257) Very Good (N = 33)
40
exam will make their vision
instructions are meant to better
40
20
scans), and that the dilated eye
N = 295
Friendliness of Staff (%)
100
80
Two hundred eighty seven patients
(97.3%) responded that the friendliness
and courteousness of the administrative
staff was “Excellent” or “Very Good.”
80.7%
60
40
16.6%
20
2.7%
0
0.0%
Excellent (N = 238) Very Good (N = 49)
N = 295
Likely to Recommend (%)
100
80
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.
83.1%
60
40
20
13.9%
2.7%
0
0.3%
Extremely Likely (N = 245) Very Likely (N = 41)
Likely (N = 8) Not Likely (N = 1)
N = 295
41
Ocular Immunology and Uveitis Service:
Percentage of Patients on Systemic Immunomodulatory Therapy
Patients treated with systemic medications (%)
50
40
30
27.2%
19.5%
20
10
0
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.
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 antiinflammatory 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).
Treatment for uveitis (i.e.,
inflammation inside the eye) and
other ocular inflammatory
conditions requires a multidisciplinary 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.
42
Vision Rehabilitation Service:
Vision-Specific Quality of Life Outcomes
NEI VFQ-25 vision-specific quality of life mean scores
100
The four NEI VFQ-25
90
45-66
80
39-46
46-59
57-66
61.8
30-38
60
50
improvement were general
55-57
70
34-43
subscales with greatest
45-54
vision, near vision, mental
health, and dependency.
55.6
51.4
50.3
49.0
45.0
42.3
41.4
40
30
20
10
0
General vision
Near vision activities
Mental health
Dependency
Pre-Rehabilitation (N = 82)
Post-Rehabilitation (N = 82)
Previous Reported Outcome Studies2,3
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
IVI vision-specific
quality of life mean scores
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.
3.0
2.0
1.43
1.19
1.54
1.22
1.42
1.20
1.47
1.27
1.0
0.0
Total
Reading
Mobility
Well-being
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.
Patients reported
improvement on all IVI
subscales with the greatest
improvement for reading.
Pre-Rehabilitation (N = 82)
Post-Rehabilitation (N = 82)
43
Vision Rehabilitation Service:
Patient Satisfaction Survey
Quality of Service (%)
100
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.
90%
80
60
40
20
9.2%
0
0.8%
0.0%
Excellent (N = 236) Above Average (N = 24)
99% of patients treated by
the Vision Rehabilitation
Service rated the quality
of service as either “Excellent”
or “Above Average.”
Average (N = 2) Explanation of
rehabilitation options (%)
Poor (N = 0) 100
N = 262
Ninety-five percent of patients
reported that the explanation of
their rehabilitation options was
either “Excellent” or “Above
Average.”
87.4%
80
60
40
20
8.0%
3.4%
0
0.0%
1.1%
Average (N = 9) Poor (N = 0)
No Response (N = 3) 95.4%
100
Interaction with staff (%)
N = 262
One hundred percent of patients rated
their interactions with staff as “Excellent”
or “Above Average.”
80
60
Based on their experience,
99% of patients said they
would recommend the
Mass. Eye and Ear Vision
40
Rehabilitation Service to
20
4.6%
0
friends or family.
0.0%
Average (N = 0) Poor (N = 0) 44
N = 262
0.0%
OTOLARYNGOLOGY
DEPARTMENT
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.
45
Department of Otolaryngology
Massachusetts Eye and Ear, Harvard Medical School
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
Clinical Affiliations
• Massachusetts General Hospital (MGH)
-M
ass. 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)
-M
ass. 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 communitybased 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
-M
ass. Eye and Ear specialists provide comprehensive vestibular diagnostic
For more information about
the Mass. Eye and Ear Quality
Program or the Department
services, as well as otologic and neurologic assessment and care in a specialty
of Otolaryngology, please
clinic housed at the Braintree Rehabilitation Hospital.
visit our website at
www.MassEyeAndEar.org.
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 worldrenowned 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
Otolaryngology
Distribution of Otolaryngology Diagnoses
Facial/glands
1%
Neurological
2%
Oral Cavity
1%
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).
Other
7%
Laryngeal
2%
Neck
2%
Trauma
3%
Skin/joints
4%
Post-operative
5%
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.
Figure 1: Distribution of head
and neck systems by frequency of
presenting complaints
Pharyngeal
esophageal
11%
Nasal/sinus
12%
Auditory/
vestibular
50%
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
Distances Traveled for Specific Diagnoses
at the Massachusetts Eye and Ear Emergency Department
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.
MEEI
Less than 19
19-267
267-3712 3712 and above
Min: 6 (019)
Max: 3991 (017)
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).
12
Median Travel Distances (miles)
10
8
6
4
2
0
Impacted
Cerumen
Epistaxis
Otitis
Externa
PTA
Sinusitis
Trauma
Hearing
Loss
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
Pediatric Otolaryngology
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
Patients Undergoing Laryngotracheal
Reconstruction Requiring Narcotic
Prescription at Discharge
18
100
16
90
Healthcare Improvement (IHI)
14
80
methodology,2 the Pediatric
Using the Institute for
Airway, Voice and Swallowing
70
12
Percentage (%)
Wean Duration (days)
Duration of Narcotics Wean after
Laryngotracheal Reconstruction
10
8
6
Center formed a multidisciplinary
60
team, including attending
50
pediatric otolaryngologists,
40
pediatric intensivists, hospitalists,
30
fellows, residents, nurses,
4
20
pharmacists and social workers to
2
10
0
0
2011-2012
2012-2014
address issues related to sedation
taper at Mass. Eye and Ear and
2011-2012
2012-2014
Mass General.
The team implemented a
system-wide process change that
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
significantly reduced the time
required for sedation wean and
decreased the number of
patients leaving the hospital
with a narcotic prescription.
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
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.
Rate of decannulation
Decannulated/ready for decannulation
Narrow airway
Chronic lung disease
When compared to other published reports of patients undergoing single-stage LTRs (operationspecific 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.
52
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.
Audiology
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
Hearing aid manufacturers
1.00
provide audiometric threshold
Probability of Ownership
loss criteria (fitting ranges) as
0.75
guidelines for fitting hearing aids
ormal word
n
performance
(in quiet)
0.50
to patients. These are easy to
apply, but provide only a glimpse
at the patient’s potential for
benefit.
0.25
We found that a different
hearing variable, improved word
recognition with level, is
0.00
consistent with ownership
0
25
50
75
100
125
Level (dBHL) of 50% Predicted Performance [SII]
outcomes. Using this variable
clinically results in a more
conservative fitting criterion, but
one that may better identify
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.
those who can benefit from
hearing aid use.
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
Otology and Neurotology
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.
Bone
overlying SSC
Ampulla
Bone
overlying SSC
Ampulla
Intact SSC
54
Arcuate eminence defect
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
30
25
SSCD may result in a number
25
25
including aural fullness (pressure
20
20
Number of Patients
of bothersome symptoms,
24
19
in the affected ear), dizziness or a
spinning sensation, autophony
15
(sensitivity to loud noise) or
tinnitus (pulsating ringing).
10
15
A review of surgical outcomes
10
6
5
0
especially autophony and
3
3
pressure, are alleviated with
0
0
Autophony
Aural
Fullness
Imbalance
revealed that auditory symptoms,
Pressure
Tinnitus
surgery for superior semicircular
canal dehiscence syndrome.
Preoperative
Postoperative
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)
55
Vestibular
The Vestibular Division at Mass. Eye and Ear brings together otolaryngology and
Mass. Eye and Ear established
otoneurology specialists to provide care for patients with vestibular and balance disorders.
the Vestibular Division in the
Department of Otolaryngology
in July 2014, bringing together
Intratympanic Gentamicin Treatment for Ménière’s Disease Drop Attacks
otoneurology specialists who
share
Mass.clinical
Eye andand
Earresearch
established
interests
in theDivision
vestibular
the Vestibular
in the
22
296
otolaryngology and
2
3,130
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
system.
Together
they provide in
Department
of Otolaryngology
services,
including
July 2014,
bringingstate-of-thetogether
art
vestibular diagnostic
testing,
otolaryngology
and otoneurology
at
Mass. Eye
andshare
Ear’sclinical
main and
specialists
who
campus
at theinMass.
researchand
interests
the Eye
and
Ear Balance
and
Vestibular
vestibular
system.
Together
they
Center
Braintree
provideatservices,
including stateRehabilitation
Hospital.
In
of-the-art vestibular
diagnostic
addition
toMass.
clinicalEye
care,
testing, at
andthey
Ear’s
engage
in clinical
main campus
and and
at the Mass.
translational
researchand
to
Eye and Ear Balance
improve
the
lives of
Vestibular
Center
at patients
Braintree
with
vestibularHospital.
and balance
Rehabilitation
In
disorders,
in collaboration
addition tooften
clinical
care, they
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.
56
with
vestibular
basic
engage
in clinical
andscience
researchers.
formal Vestibular
translationalAresearch
to improve
Division
structural
the lives offers
of patients
with
advantages
andbalance
further disorders,
vestibular and
positions
the Otolaryngology
often in collaboration
with
Department
at Mass.
Eye
vestibular basic
science
and
Ear as a A
leader
in Vestibular
this area
researchers.
formal
of
expertise.
Division
offers structural
advantages and further positions
the Otolaryngology Department
at Mass. Eye and Ear as a leader
in this area of expertise.
Head and Neck Oncology
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 Rates
In 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
The study of free flap surgical
site infection rates at Mass. Eye
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
and Ear included the most flaps
(479) and is among the lowest
infection rates (13.2%) in a
comparison of similar series.
57
Commonly Used Prophylactic Antibiotics in Free Tissue Transfer Reconstructive Surgery
2%
3%
1%
2%
0.2%
83%
9%
Continually tracking and
Ampicillin/Subactam
assessing infectious
Clindamycin
complications occurring in
association with advanced head
Cefazolin
and neck cancer surgery allows
Vanco +/-
for the institution and evaluation
Clinda/Levo
of evolving protocols to further
Other
decrease the frequency and
negative side effects of these
None
occurrences. Similarly,
appropriately directed antibiotic
use as part of such protocols can
curtail the evolution of
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.
challenging antibiotic resistant
organisms.
Shoulder Function Following Reconstruction with the Supraclavicular Artery Island Flap
10
In the right patient, the
supraclavicular artery island flap
Number of Patients
8
provides an excellent
6
4
Excellent
reconstructive option without
Good
creating additional morbidity and
Fair
helping to optimize quality of
Poor
2
given the morbidity created by a
patient’s cancer.
0
Penn Shoulder
Score
Constant
Shoulder Score
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 nonoperated 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
life. This finding is important
Laryngology
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,
• Botox® treatment for spasmodic
socially and professionally. Affecting close to 50,000 people in the United States, it
dysphonia is effective, offering
is a type of focal dystonia, a neurological disease where the brain sends too many
17 weeks of good voice after
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.
4 weeks of breathy voice.
• Long-term Botox® dose
remains stable over years of
treatment for most patients.
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.
•T
he average patient returned
for re-injection every 182 days.
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
•T
he average age at first
injection was 53 years.
•M
ore women are affected
than men (70% women).
•9
6 percent had adductor type
spasmodic dysphonia.
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
• Botox® injections are fast,
from 2.35 units to 2.36 units. This patient cohort underwent an average of 14
well tolerated and restore
injections with a mean time of 182 days between injections. They experienced 4 weeks
good vocal function.
of breathiness after the injection followed by 17 weeks of good voice before needing
another injection.
59
Rhinology
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
Percent of Patients Reporting Problems
100
80
60
40
20
0
Performing
Daily Activities
Pain &
Discomfort
Anxiety &
Depression
Patients with Chronic Sinusitis — No Surgery
General Population
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.
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 costeffectiveness and to assess
quality of life benefits following
treatment for sinus disease.
Changes in Quality of Life after Sinus Surgery
Percent of Patients Reporting Problems
100
80
60
40
20
0
Performing
Daily Activities
Pain &
Discomfort
Anxiety &
Depression
Patients with Chronic Sinusitis Before Surgery
After Surgery
60
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.
2
Remenschneider 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.
Facial Plastic and Reconstructive Surgery
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.
66.42
all subjects
21.85
(SD = 20.68) n = 54
22.33
(SD = 23.05) n = 45
61.79
internal nasal valve
(Group 1)
13.46
4.09
(SD = 20.25) n = 60
(SD = 23.34) n = 14
(SD = 19.19) n = 13
59.60
22.69
18.85
(SD = 20.69) n = 16
(SD = 15.22) n = 13
(SD = 17.34) n = 13
72.17
internal and
external nasal valve
(Group 3)
25.36
20
30
(SD = 17.30) n = 30
(SD = 22.93) n = 28
34.05
10
indicate improved quality of life
(SD = 7.35) n = 11
External nasal valve
(Group 2)
0
On the NOSE scale, lower scores
40
(SD = 25.03) n = 21
50
60
70
80
Score
Baseline, Mean
1-3 Months, Mean
6-12 Months, Mean
61
(SOS: Sleep Outcomes Survey)
58.45
all subjects
80.44
78.93
64.62
internal nasal valve
(Group 1)
On the SOS scale, higher scores
(SD = 18.24) n = 60
(SD = 17.28) n = 50
(SD = 18.46) n = 46
(SD = 22.57) n = 14
83.00
77.91
55.76
External nasal valve
(Group 2)
(SD = 18.77) n = 11
(SD = 22.00) n = 11
(SD = 17.69) n = 16
83.35
(SD = 10.46) n = 10
85.09
57.21
internal and
external nasal valve
(Group 3)
78.14
10
20
30
40
50
60
(SD = 16.26) n = 13
(SD = 16.43) n = 30
75.80
0
70
80
(SD = 18.71) n = 27
(SD = 18.13) n = 22
90
Score
Baseline, Mean
1-3 Months, Mean
6-12 Months, Mean
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, utilizing 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.
On the NOSE scale, lower scores
Preoperative
_ SD)
(mean +
36.6
Postoperative
_ SD)
(mean +
16.76
0
5
10
15
20
_ 17.37)
(SD = +
25
30
35
Score (p-Value: < 0.001)
62
40
_ 27.1)
(SD = +
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])
63
Thyroid and Parathyroid Endocrine Surgery
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,
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
the first such series in the world literature, which included many different genres of
have had extensive, specialized
performers, including 44% classical/operatic, 19% religious (including 1 Gospel, 1 Jewish
experience operating on
Cantor and 3 Choir), 25% pop/rock, 11% country & blues/folk, 4% Motown, 7% musical
professional voice users.
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
Figure 1. Percentages of different genres of professional voice users in the study
These surgical outcomes show
(with some patients indicating multiple genres of performance)
that thyroid surgery is safe and
effective for professional voice
users. By following key elements
Classical/
Operatic
44%
Pop/Rock
in 100% of singers and
professional voice users with the
19%
mean time to return to
Country and
Blues/Folk
professional performance being
11%
2.26 months.
Musical
theater
7%
Music
teacher
7%
Other
7%
Motown
4%
0
5
10
15
20
25
30
35
40
45
50
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)
Mean Score
Vocal Genre
professional performance after
thyroid surgery can be achieved
25%
Religious
of operative approach, return to
14
A comparison of preoperative vs.
12
postoperative voice instrument
10
scores showed no difference in
quality of life after surgery.
8
Preoperative
6
Postoperative
4
2
0
VHI
SVHI
EASE
Vocal instruments
65
66
Massachusetts Eye and Ear Infirmary
NURSING
DEPARTMENT
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 evidencebased 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.
67
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
100
86
89
91
91
86
91
97
Database of Nursing Quality
80
Percentage
As a member of the National
Indicator (NDNQI®), the
Department of Nursing has
60
chosen the RN survey with
40
Practice Environment Scale (PES)
survey tool for this annual
20
assessment of the Nursing
Practice Environment.
0
2007
2008
2009
2010
2011
2012
2013
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
3.0
2.82
2.86
2.91
2.89
2.91
2.99
2.98
Using a 1-4 scale, our nurses
assessed the quality of the care
2.5
they delivered. Elements of this
assessment included the high
2.0
standards of nursing care
1.5
expected, competence of their
peers, and the presence of a
1.0
clearly defined philosophy of
nursing.
0
2007
68
2008
2009
2010
2011
2012
2013
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).
Mass. Eye and Ear’s mission and
vision seeks to promote
excellence in clinical care,
Collegial Nurse-Physician Relations
3.0
2.85
2.84
2.75
teaching and research. In support
2.80
2.95
2.98
2.97
of this, the organization provides
several avenues that foster
collegial nurse-physician
2.5
relations. The data reflects a
2.0
strong culture of collegiality
among nurses and physicians.
1.5
1.0
0
Nurses and physicians practice
2007
2008
2009
2010
2011
2012
2013
Team-Based Simulations to
enhance crisis management of
medical emergencies. Mass. Eye
and Ear has a robust participation
in Schwartz rounds, which are
Nurse Quality Indicators (NDNQI )
®
committed to providing the
Nurses felt they had enough time
with their patients
Nurses felt their discharged patients
were adequately prepared
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
2012, NO
2013, NO
2012, NO
2013, NO
0.26, 26%
0.22, 22%
0.07, 7%
0.06, 6%
2012, YES
2013, YES
2012, YES
2013, YES
0.74, 74%
0.78, 78%
0.93, 93%
0.94, 94%
collegiality.
69
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
The PUP study team consists of
the Adult Unit’s Nursing
of their life. The aim of the Nursing Department is to prevent hospital acquired pressure
Leadership, a Nursing Staff
ulcers through identifying patients at risk to develop pressure ulcer and conducting routine
Champion and a Staff Specialist
skin assessments. Monthly Pressure Ulcer Prevalence (PUP) rounds are conducted with a
from the Center for Quality &
team of nursing staff members to identify patients at risk and to ensure compliance with
Patient Safety. The team is
prevention strategies. These prevention strategies are incorporated into the unit’s
guided by the National Quality
purposeful rounding. Through the end of 2013, the Adult Unit has been Pressure Ulcer free
Forum’s Nurse Sensitive Care
for 306 days.
Outcome Measure®.
The PUP study, initially
Rate per 1,000 patient days
2.5
2.0
conducted quarterly, was
increased to a monthly frequency
1.75
at the beginning of the 2013
1.56
fiscal year and continues on a
1.5
monthly basis.
1.0
.85
0.5
0
0.0
Stage II
or greater
2011
0
Stage III
or greater
2011
Stage II
or greater
2012
Stage II
or greater
2012
0
Stage II
or greater
2013
Stage II
or greater
2013
Hand Hygiene
100
Hand hygiene is the single most
90
90% Mass. Eye and Ear Benchmark
70
The health care worker
Percent
60
performs hand hygiene
50
40
30
representatives from all
disciplines. Monitoring,
or alcohol hand gel
combined with education and
before each direct patient
contact with soap and water
0
2011
2012
2013
checks are performed by
contact with soap and water
performs hand hygiene
10
Unannounced, randomized spot
before each direct patient
The health care worker
20
70
important way to prevent the
transmission of infection.
80
or alcohol hand gel
feedback, has resulted in high
levels of employee compliance.
Improving Outcomes through
Pediatric Simulation Program:
Pediatric Simulated Cardiopulmonary
Resuscitation Event Response
2011 — Year One
The primary goals of the pediatric
Enhanced knowledge base and skills of nurses, residents, fellows, and attendings
simulation program are to
required to effectively manage pediatric codes within the pediatric unit. Empowered staff
increase team building and
through team training and role identification.
improve clinical skills, response
times and closed-loop
communication.
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
50
The Emergency Department
nurses implemented Hourly
Patient Rounding to keep
patients informed, manage
30
patient’s pain, discuss plan of
20
care and duration and continually
conduct patient assessments and
10
need for care.
Nov-13
Sep-13
Jul-13
May-13
Mar-13
Jan-13
Nov-12
Sep-12
Jul-12
May-12
Mar-12
0
Jan-12
number of patients
40
Success has been found
through accountability and
consistency. The core culture of
rounding is an integrated aspect
of the Emergency Department’s
Hardwiring Patient Rounding in the Emergency Department resulted in major
team approach to quality patient
improvements including reduced elopement rates (patients who leave before being seen).
care.
71
Participation in National Conferences
2013 SOHN 37th Annual Congress Vancouver, BC, CA -
Why I love my job
Society of Otorhinolaryngology and Head and Neck Nurses
and Mass. Eye and Ear
Hope for Breaking the Silence: Cochlear Implants vs. Auditory Brain Stem Implants
Mass. Eye and Ear is my home
Andria Ledoux, R.N.
“I Am So Dizzy, My Head is Spinning” — Interventions of Meniere’s Disease
Amy Hanby, B.S.N., R.N.
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
Post-operative Bleeding after a Tonsillectomy or Tonsillectomy and Adenoidectomy as a
currently work in a very different
Common Complication
job position, I am honored to
Shanna Pagliuca, R.N.
work in such a great family
atmosphere. I have seen
Development of a Transition of Care for Pediatric Patients with Critical Airway Conditions
across Institutions
Kevin Callans, B.S.N., R.N.
enormous growth among staff
throughout the years.
Mass. Eye & Ear provides a
supportive environment that has
encouraged my professional
Building a Bridge… Finding a Voice
growth. I love the variety and
Ann Goulette, R.N., Jane Gallagher, R.N., & Kevin Callans, B.S.N., R.N.
daily challenges in my current
operating room nurse position.
I am continually learning and
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.
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,
Hardwiring Patient Rounding in the Emergency Department at
Your proud employee,
Nancy Kotzuba, R.N., M.S.N.
Maureen Martinez, M.S., R.N.
72
The DAISY Foundation
The founders of the DAISY Foundation wanted to say “thank you” to nurses everywhere
DAISY is an acronym for
by establishing a recognition program to honor the super-human work nurses do for
Diseases Attacking the Immune
patients and families every day. Nearly 1,700 healthcare facilities internationally, inpatient
System. The Foundation was
and ambulatory care facilities from urban teaching hospitals to small rural community
formed in November, 1999, by
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,
the family of J. Patrick Barnes
who died at age 33 of
complications of Idiopathic
Thrombocytopenic Purpura (ITP).
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.”
73
Ophthalmology Department Full-time and
Affiliate Medical Staff and Practice Locations
Ophthalmology Central Referral and
Glaucoma
Optometry/Contact Lens
Appointments Phone: 617-573-3202
617-573-3670
617-573-3185
Service Director: Louis R. Pasquale, M.D.,
Service Director: Amy C. Watts, O.D.
F.A.R.V.O.
Medical Director: James Chodosh, M.D., M.P.H.
Location: Mass. Eye and Ear Infirmary,
Associate Service Director: Angela V. Turalba, M.D.
Andrew D. Baker, O.D.
243 Charles Street, Boston, MA
Teresa C. Chen, M.D.
Mark M. Bernardo, O.D.
Iryna A. Falkenstein, M.D.
Shannon Bligdon, O.D.
Comprehensive Ophthalmology and
Cynthia L. Grosskreutz, M.D., Ph.D.
Calliope Galatis, O.D.
Cataract Consultation
Ambika S. Hoguet, M.D.
Matt Goodman, O.D.
617-573-3202
Pallavi Ojha, M.D.
Kevin E. Houston, O.D.
Service Director: Sherleen H. Chen, M.D., F.A.C.S.
Lucy Q. Shen, M.D.
Yan Jiang, O.D., Ph.D.
Sheila Borboli-Gerogiannis, M.D., F.A.C.S.
Brian J. Song, M.D.
Charles D. Leahy, O.D., M.S.
Stacey C. Brauner, M.D.
Janey L. Wiggs, M.D., Ph.D.
Brittney J. Mazza, O.D.
Lotfi B. Merabet, O.D., Ph.D., M.P.H.
Han-Ying Peggy Chang, M.D.
Amy Scally, O.D.
Matthew F. Gardiner, M.D.
Neuro-Ophthalmology and Adult Strabismus
Scott H. Greenstein, M.D., F.A.C.S.
617-573-3412
Kristine Lo, M.D.
Service Director: Joseph F. Rizzo, III, M.D.
Pediatric Ophthalmology and Strabismus
Christian E. Song, M.D.
Dean M. Cestari, M.D.
(a collaboration on-site with Children’s Hospital)
John W. Gittinger, M.D.
617-355-6401
Simmons Lessell, M.D.
Ophthalmologist-in-Chief, Boston Children’s
Cornea and External Disease
Hospital: David G. Hunter, M.D., Ph.D.
617-573-3938
Service Director: Reza Dana, M.D., M.Sc.,
Ocular Tumors
Service Director, Mass Eye and Ear: Melanie
M.P.H., F.A.R.V.O.
617-573-3202
A. Kazlas, M.D.
Associate Service Director: James Chodosh,
Anna Maria Baglieri, O.D.
M.D., M.P.H.
Kathryn A. Colby, M.D., Ph.D.
Kimberley Chan, O.D.
Joseph B. Ciolino, M.D.
Suzanne K. Freitag, M.D.
Linda R. Dagi, M.D.
Kathryn A. Colby, M.D., Ph.D.
Evangelos S. Gragoudas, M.D.
Alexandra T. Elliot, M.D.
Claes H. Dohlman, M.D., Ph.D.
Ivana K. Kim, M.D.
Anne B. Fulton, M.D.
Pedram Hamrah, M.D.
Daniel R. Lefebvre, M.D.
Gena Heidary, M.D., Ph.D.
Deborah S. Jacobs, M.D.
Michael K. Yoon, M.D.
Suzanne C. Johnston, M.D.
Danielle M. Ledoux, M.D.
Ula V. Jurkunas, M.D.
Deborah P. Langston, M.D., F.A.C.S.
Ophthalmic Pathology
Iason Mantagos, M.D.
Samir A. Melki, M.D., Ph.D.
617-573-3319
Kathryn B. Miller, O.D.
Roberto Pineda, II, M.D.
Service Director: Frederick A. Jakobiec, M.D., D.Sc.
Robert A. Petersen, M.D., D.M.Sc.
Peter B. Veldman, M.D.
Thaddeus P. Dryja, M.D.
Ankoor S. Shah, M.D., Ph.D., M.S.
Rebecca Stacy, M.D., Ph.D.
Lois E. H. Smith, M.D., Ph.D.
Deborah K. VanderVeen, M.D.
Emergency Ophthalmology and Eye Trauma
Carolyn S. Wu, M.D.
Emergency Department: 617-573-3431
Ophthalmic Plastic Surgery
Service Director: Matthew F. Gardiner, M.D.
617-573-5550
Maggie B. Hymowitz, M.D.
Service Director: Suzanne K. Freitag, M.D.
Refractive Surgery
Eye Trauma: 617-573-3022
Nahyoung Grace Lee, M.D.
617-573-3234
Service Director: Alice C. Lorch, M.D. (AY15)
Service Director: Roberto Pineda, II, M.D.
Yewlin Erin Chee, M.D. (AY14)
Francis C. Sutula, M.D.
Ula V. Jurkunas, M.D.
Michael K. Yoon, M.D.
Samir A. Melki, M.D., Ph.D.
74
Retina Service
Location: Mass. Eye and Ear/East Bridgewater,
Location: Mass. Eye and Ear/Stoneham,
617-573-3288
400 North Bedford Street, East Bridgewater, MA,
One Montvale Avenue, Stoneham, MA,
Service Director: Evangelos S. Gragoudas, M.D.
Phone: 508-378-2058
Phone: 781-279-4418
Associate Service Director: Dean Eliott, M.D.
Site Director: Angela V. Turalba, M.D.
Site Director: Matthew F. Gardiner, M.D. Jason I. Comander, M.D., Ph.D.
(Glaucoma)
(Comprehensive/Cataract)
Deeba Husain, M.D.
Stacey C. Brauner, M.D.
Ivana K. Kim, M.D.
Leo A. Kim, M.D., Ph.D.
Louis R. Pasquale, M.D., F.A.R.V.O.
Pedram Hamrah, M.D. (Cornea)
John I. Loewenstein, M.D.
(Glaucoma)
Ambika S. Hoguet, M.D. (Glaucoma)
Joan W. Miller, M.D., F.A.R.V.O.
Demetrios Vavvas, M.D., Ph.D. (Retina)
Charles D. Leahy, O.D., M.S. (Optometry)
(Ophthalmic Plastic Surgery)
George N. Papaliodis, M.D.
Shizuo Mukai, M.D.
Lucia Sobrin, M.D., M.P.H.
Location: Mass. Eye and Ear/Longwood,
Demetrios Vavvas, M.D., Ph.D.
800 Huntington Avenue, Boston, MA,
Amy Scally, O.D. (Optometry)
David M. Wu, M.D., Ph.D.
Phone: 617-936-6100
Christian E. Song, M.D. (Comprehensive/
Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.
Site Director: Carolyn E. Kloek, M.D.
Angela V. Turalba, M.D. (Glaucoma)
Mark M. Bernardo, O.D. (Optometry)
Peter B. Veldman, M.D. (Cornea)
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.
Sheila Borboli-Gerogiannis, M.D., F.A.C.S.
(Comprehensive/Cataract, Cornea/
Refractive)
(Comprehensive, Cornea)
Iryna A. Falkenstein, M.D. (Glaucoma)
Yan Jiang, O.D., Ph.D. (Optometry)
(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,
(Comprehensive/Cataract, Uveitis)
Cataract, Cornea/Refractive)
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)
Mass. Eye and Ear/Tele-Retinal Imaging
30 Man Mar Drive, Suite 2, Plainville, MA,
Program Director: Louis R. Pasquale, M.D.,
Phone: 508-695-9550
Nahyoung Grace Lee, M.D. (Ophthalmic F.A.R.V.O.
Location: Mass. Eye and Ear/Providence,
Leo A. Kim, M.D., Ph.D.
One Randall Square, Suite 203, Providence,
Christian E. Song, M.D. (Comprehensive/
Carolyn E. Kloek, M.D.
RI, Phone: 401-453-4600
Brian J. Song, M.D.
Southern New England Retina Associates
Karen L. Zar, O.D. (Optometry)
Demetrios Vavvas, M.D., Ph.D.
Site Director: Magdalena Krzystolik, M.D.
David M. Wu, M.D., Ph.D.
Plastic Surgery)
Cataract, Cornea/Refractive)
(Retina)
Paul B. Greenberg, M.D. (Retina)
75
Otolaryngology Department Medical Staff
Emergency Otolaryngology
Alicia M. Quesnel, M.D., 617-573-3503
Mass. Eye and Ear, East Bridgewater
Emergency Department: 617-573-3431
Steven D. Rauch, M.D., 617-573-3644
Main Line, 508-378-2059
Service Director: H. Gregory Ota, M.D.
Felipe Santos, M.D., 617-573-3936
Audiology Services, 508-350-2800
Konstantina M. Stankovic, M.D., Ph.D.,
Mandana R. Namaranian, M.D.
General Otolaryngology
617-573-3972
Mass. Eye and Ear, Medford
Gregory W. Randolph, M.D., F.A.C.S.*
,
617-573-4115
Vestibular
781-874-1965
Jean M. Bruch, D.M.D., M.D., 617-573-3793
Steven D. Rauch, M.D.*
, 617-573-3644
H. Gregory Ota, M.D.
John M. Dobrowski, M.D., 617-573-4104
Richard F. Lewis, M.D., 617-573-3501
David M. Bowling, M.D.
Allan J. Goldstein, M.D., 617-573-3705
Adrian J. Priesol, M.D., 617-573-4148
Gregory T. Whitman, M.D., 617-573-6700
Mass. Eye and Ear, Newton-Wellesley
617-630-1699
Facial Plastic and Reconstructive Surgery
Tessa A. Hadlock, M.D.*
, 617-573-3641
Pediatric Otolaryngology
Mark F. Rounds, M.D.*
Richard E. Gliklich, M.D., 617-573-4105
Christopher J. Hartnick, M.D.*
, 617-573-4206
Maynard C. Hansen, M.D.
Linda N. Lee, M.D., 617-573-4105
Michael S. Cohen, M.D., 617-573-4250
Brian J. Park, M.D.
Robin W. Lindsay, M.D., 617-573-3778
Donald G. Keamy, Jr., M.D., 617-573-4208
Kathryn A. Ryan, M.D.
David A. Shaye, M.D., 617-573-4105
Daniel J. Lee, M.D., F.A.C.S., 617-573-3130
Leila A. Mankarious, M.D., 617-573-4103
Mass. Eye and Ear, Quincy
617-774-1717
Skin Cancer and Mohs Surgery
Jessica L. Fewkes, M.D., 617-573-3789
Rhinology
Paul M. Konowitz, M.D., F.A.C.S.*
Molly Yancovitz, M.D., 617-573-3789
Eric H. Holbrook, M.D.*
, 617-573-3209
Peter N. Friedensohn, M.D.
Stacey T. Gray, M.D., 617-573-4188
Alex Grilli, M.D.
Laser Reconstructive Surgery
Benjamin S. Bleier, M.D., 617-573-6966
John B. Lazor, M.D., M.B.A., F.A.C.S.
Oon Tian Tan, M.D., Ph.D., 617-573-6493
Nicolas Y. Busaba, M.D., F.A.C.S., 617-573-3558
Mandana R. Namiranian, M.D.
Head and Neck Surgical Oncology
Thyroid and Parathyroid Endocrine Surgery
Derrick T. Lin, M.D., F.A.C.S.*
, 617-573-3502
Gregory W. Randolph, M.D., F.A.C.S.*
,
Mass. Eye and Ear, Stoneham
Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100
617-573-4115
781-279-0971
Kevin S. Emerick, M.D., 617-573-4084
Paul M. Konowitz, M.D., 617-573-4084
Michael B. Rho, M.D.*
Mark A. Varvares, M.D., 617-573-3192
David J. Lesnik, M.D., 781-279-0971
David J. Lesnik, M.D.
Derrick T. Lin, M.D., F.A.C.S., 617-573-3502
Dukhee Rhee, M.D.
Suburban Centers
Mass. Eye and Ear, Weymouth-Duxbury
Edward J. Reardon, M.D.
Laryngology
Ramon A. Franco, Jr., M.D.*
, 617-573-3958
781-337-3424
Jean M. Bruch, D.M.D., M.D., 617-573-3793
Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100
Mass. Eye and Ear, Balance and Vestibular
Cathy D. Chong, M.D.
Christopher J. Hartnick, M.D., 617-573-4206
Center at Braintree Rehabilitation Hospital
Amee K. Dharia, M.D.
Phillip C. Song, M.D., 617-573-3557
617-573-6700
Hani Z. Ibraham, M.D., F.A.C.S.
Steven D. Rauch, M.D.*
David S. Kam, D.M.D., M.D.
Gregory T. Whitman, M.D.
Monica S. Lee, M.D.
D. Bradley Welling, M.D., Ph.D.**
, 617-573-3632
Mass. Eye and Ear, Concord
Otolaryngology Referral Line
Ronald K. de Venecia, M.D., Ph.D., 617-573-3715
978-369-8780
617-573-3954
David H. Jung, M.D., Ph.D., 617-573-3130
Michael H. Fattal, M.D.
Daniel J. Lee, M.D., F.A.C.S., 617-573-3130
Jennifer Setlur, M.D.
*denotes division leadership
Michael A. Williams, M.D.
**denotes chair of the department
Otology and Neurotology
Michael J. McKenna, M.D.*
, 617-573-3672
76

MASSACHUSETTS EYE AND EAR

Transcription

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