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Page 1: Ophthalmology and Otolaryngology

M A S S A C H U S E T T S E Y E A N D E A R

Quality and Outcomes 2014

243 Charles Street

Boston, MA 02114-3096

617-523-7900

617-523-5498 (T.D.D.)

MassEyeAndEar.org

Page 2: Ophthalmology and Otolaryngology

Contributors

Olumuyiwa Adebona

Shakhsanam Aliyeva

John Anderson

Christopher Andreoli

Olamide Awosanya

Sandra Baptista-Pires

Linda Belkner

Jean Bibeau

Sheila Borboli-Gerogiannis

Stacey Brauner

Charlene Callahan

Dean Cestari

Kenneth Chang

Peggy Chang

Wendy Chao

Yewlin Chee

Sherleen Chen

Teresa Chen

James Chodosh

Janet Cohan

Louise Collins

Lisa Cowan

Laura D’Amico

Linda Dagi

Reza Dana

Mindy Davis

Suzanne Day

Sandy DeCelle

Peter Delisle

Daniel Deschler

Gillian Diercks

April Dobbs

Claes Dohlman

Anne Marie Donnelly

Dean Eliott

Tobias Elze

Kevin Emerick

Kimberly Farwell

Tanya Fedyshyn

John Fernandez

Cherie Florio

Ramon Franco

Martha Fraser

Suzanne Freitag

Sandra Gallagher

Matthew Gardiner

Amanda Goggin

Evangelos Gragoudas

Stacey Gray

Scott Greenstein

Tessa Hadlock

Christopher Halpin

Christopher Hartnick

Eric Holbrook

David Hunter

Mary-Lou Jackson

Maryann Jerrier

Grace Jonak

Justin Kanoff

Dipti Karmani

Melanie Kazlas

Ivana Kim

Leo Kim

Carolyn Kloek

Elliott Kozin

Sharon Kujawa

Anne Marie Lane

Mary Leach

Daniel Lee

Daniel Lefebvre

Kathleen Lennon

Patricia Li

Derrick Lin

Robin Lindsay

Ann-Marie Lobo

John Loewenstein

Katie Luo

Joe Marshall

Maureen Martinez

Kathy McCormack

Fran McDonald

Michael McKenna

Lisa McLellan

Ralph Metson

Joan Miller

John Miller

Alfred Minincleri

Nicolas Moretti

Anne Murphy

Garyfallia Pagonis

George Papaliodis

Louis Pasquale

Eric Pierce

Roberto Pineda

Corinne Powers

Suzette Profio

Andrew Rabkin

Gregory Randolph

Nikhila Raol

Steven Rauch

Michael Reinhart

Aaron Remenschneider

Mike Ricci

Debbie Rich

Joseph Rizzo

Debra Rogers

Barbara Scully

Alexandra Selivanova

Jennifer Street

Debra Trocchi

Angela Turalba

Joseph Vadakekalam

Peter Veldman

Rhonda Walcott-Harris

Suzanne Ward

Rachel Wasserstrom

Amy Watts

Bradley Welling

Julia Wong

Janet Yedziniak

Lucy Young

Medical Illustrations by:

Laurel Cook Lhowe

Graphic Design by:

Marc Harpin,

Rhumba Design

Members of the Mass. Eye

and Ear Quality Steering

Committee also include:

Linda Belkner, R.N.

Director, Quality and

Patient Safety

Mary Kennedy

Risk Manager

Michael Ricci

Chief Information Officer

Clinical Leadership in Quality: 2014

Sunil Eappen, M.D.Assistant Professor of Anaesthesia, Harvard Medical SchoolChief Medical Officer, Chief of Anesthesiology, Massachusetts Eye and Ear

Joan W. Miller, M.D.Henry Willard Williams Professor and Chair of Ophthalmology, Harvard Medical SchoolChief of Ophthalmology, Massachusetts Eye and Ear, Massachusetts General Hospital

D. Bradley Welling, M.D., Ph.D.Walter Augustus LeCompte Professor and Chair of Otology and Laryngology, Harvard Medical SchoolChief of Otolaryngology, Massachusetts Eye and Ear, Massachusetts General Hospital

Hugh Curtin, M.D.Professor of Radiology, Harvard Medical SchoolChief of Radiology, Massachusetts Eye and Ear

Teresa C. Chen, M.D.Associate Professor of Ophthalmology, Harvard Medical SchoolChief Quality Officer, Department of Ophthalmology, Massachusetts Eye and Ear

Christopher J. Hartnick, M.D., M.S.Professor of Otology and Laryngology, Harvard Medical SchoolVice Chair of Safety and Quality/Clinical Research, Department of Otolaryngology, Massachusetts Eye and Ear InfirmaryDirector, Division of Pediatric Otolaryngology, Massachusetts Eye and Ear

Eileen Lowell, R.N., M.M.Vice President of Patient Care Services, Chief Nursing Officer, Massachusetts Eye and Ear

Page 3: Ophthalmology and Otolaryngology

Please note that information

contained in this book focuses

primarily on the work of

the full-time staff at Mass. Eye

and Ear’s main Boston campus,

unless otherwise stated.

A Letter from the President

Dear Colleagues in Healthcare,

We are proud to present the 2014 Quality and Outcomes

Report of Massachusetts Eye and Ear. This annual report

showcases the results that are achieved by an outstanding

group of surgeons, nurses and staff who continually strive

for the best outcomes for all of our patients. These individuals work hard to ensure

each patient has the best experience possible while under our care, as well as

resulting quality of life.

We thank the Department Chiefs at Mass. Eye and Ear — Drs. Hugh Curtin,

Sunny Eappen, Joan Miller and Brad Welling — who enable us to achieve the

success reflected in the information you’ll see here. We continually evolve to

serve our patient population better, which is made up largely of people seen on

an outpatient basis. We have only 41 inpatient beds, but serve almost 27,000

surgical patients in a year. Many of the benchmarks of care in the field are being

set here at Mass. Eye and Ear, but we’re never satisfied with what we’ve achieved

and always work to improve our results. By publishing this report each year,

we can quantify and show what is being accomplished, so we can continue to

improve those outcomes.

In this report you’ll find information about our attention to patient safety,

and learn about how we use collaboration, advances in technology, and clinical

research to improve patient treatments and the results we achieve. The report

provides an avenue for transparency and accountability, which we feel is very

important. We hope to set the standard for outcomes achieved, and to be able

to document our continuing improvement through the information included in

these pages.

We also wish to thank the members of the quality team and the physicians,

nurses and other staff who work so hard to provide the highest quality care

each day.

We hope you find this publication interesting and useful. We welcome

your comments and feedback. For an electronic version of this report and to see

new innovations from Mass. Eye and Ear, please visit MassEyeAndEar.org/Quality.

John Fernandez

President & CEO

1

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Clinical Locations

Boston — Main Campus

Boston — Longwood

Boston — Joslin

Braintree

Concord

Duxbury

East Bridgewater

Medford

Milton

Newton

Plainville

Providence

Quincy

Stoneham — Montvale Avenue

Stoneham — Woodland Road

Waltham

Weymouth

For more information, visit

MassEyeAndEar.org/Locations

About Massachusetts Eye and Ear

2

Founded in 1824, Massachusetts Eye and Ear is a pre-eminent specialty,

teaching and research hospital dedicated to caring for disorders of the eyes,

ears, nose, throat, head and neck. Our dedicated staff provides primary and

subspecialty care and serves as a referral center for inpatient and outpatient

medical and surgical care.

Mass. Eye and Ear is the leading authority in its specialties throughout the

northeast and is a resource globally for advances in patient care, research

and education. As the primary academic center for Harvard Medical School’s

Departments of Ophthalmology and Otology and Laryngology, we are deeply

committed to providing a superb education to the next generation of visionary

healthcare leaders. Our world-renowned experts are continuously innovating

in the fields of translational and bench research, turning insights into cures that

benefit countless people. We continue to forge new partnerships and alliances —

locally, nationally and beyond our borders — to increase our reach and make our

expertise, services and resources available to all who need them.

Pivotal to our clinical quality efforts is the use of the Longitudinal Medical Record

(LMR), an integrated and secure system of communication and medical record sharing

among the majority of Harvard Medical School’s network of hospitals and affiliates.

This network facilitates quick and easy communication among referring physicians

and Mass. Eye and Ear’s consulting ophthalmologists, otolaryngologists and

radiologists. It also enables our physicians to instantly tap our in-house specialists,

affording seamless and rapid access to some of the best ophthalmology and

otolaryngology resources available.

2013 Hospital Statistics

(Jan. 1 – Dec. 31, 2013)

Patient Volume

Outpatient services .............................................................................................388,551

Ambulatory surgery services and laser .................................................5,242

Inpatient surgical services ...................................................................................1,116

Emergency Department services .............................................................18,547

Discharges ............................................................................................................................1,439

Beds ......................................................................................................................................................41

Overall Operating Revenue ..................................................... $369,216,877

Page 5: Ophthalmology and Otolaryngology

Massachusetts Eye and Ear

S U R G E R Y O V E R V I E W

3

The volume of surgery at Mass. Eye and Ear continued to grow

significantly this year with the opening of the Longwood operating rooms.

We continue to be the only hospital in the region to publicly report quality

outcomes data. This is our 4th consecutive year of reporting.

Page 6: Ophthalmology and Otolaryngology

Mass. Eye and Ear has 21

operating rooms between the

Main Operating Room and the

6th floor Surgical Suites at the

main campus and 4 operating

rooms at the Longwood Site

on Huntington Avenue.

Currently we only care for

adult ambulatory patients at

MEE-Longwood, but we expect

to have initiated pediatric care

in January 2015 and anticipate

offering otolaryngology and

audiology services in the

summer of 2015. Regardless

of where surgery is performed,

the same measures of quality

and care are applied across

all locations. Overall volume

has grown annually for the

past 5 years.

The ophthalmology and

otolaryngology surgical

volumes have been split fairly

evenly over the past 5 years.

This year’s difference was

spurred on by the growth of

ophthalmology volume at the

Longwood Site.

4

Mass. Eye and Ear Surgical Volume

Ophthalmology and Otolaryngology Surgical Volume

Longwood 6th Floor Surgical Suite Main Operating Room Total

Ophthalmology Otolaryngology

20,000

15,000

10,000

5,000

0

12,000

10,000

8,000

6,000

4,000

2,000

0

2008 2009

2008

2010

2009

2011 2012 2013

2010 2011 2012 2013

Num

ber

of o

pera

ting

roo

m p

roce

dure

sN

umbe

r of

ope

rati

ng r

oom

pro

cedu

res

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Mass. Eye and Ear cares for the

most pediatric otolaryngologic

patients in the area and for

more pediatric surgical patients

than anyone other than Boston

Children’s Hospital. Pediatric

surgical volume has remained

approximately one-third of

Mass. Eye and Ear’s overall

volume for the last few years.

Nausea is one of the most

common and troublesome

complications occurring after

surgery for both pediatric and

adult patients. Additionally,

it is well known that patients

undergoing both ophthalmologic

and otolaryngologic procedures

are at significantly higher risk

of postoperative nausea and

vomiting (PONV) when compared

to patients having other types

of surgery. As a result, nearly

every one of our patients receives

prophylactic treatment with the

latest combination of appropriate

antiemetic medications in order

to minimize the chances of

PONV.

5

Adult and Pediatric Volume

Adult Pediatric

Adult Pediatric

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

02008 2009 2010 2011 2012 2013

Num

ber

of o

pera

ting

roo

m p

roce

dure

s

Postoperative Nausea and Vomiting (PONV) in the Post Anesthesia Care Unit (PACU)

10.0

9.0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0PONV in

PACUDelay indischarge

Perc

enta

ge

These numbers reflect patients who had nausea and/or vomiting in the Post Anesthesia Care Unit (PACU) despite therapy in the operating room and required additional treatment to treat their discomfort. The delay in discharge criteria reported reflects the number of patients who continued to have prolonged nausea despite additional therapy. Typical reports of PONV range from 20-30% incidence. Our numbers continue to exceed all published benchmarks for PONV for ambulatory surgery patients. This is a reflection of the state of the art techniques and medications utilized, as well as the close collaboration between the nurses, anesthesiologists and surgeons in caring for these patients. The data reflects a sample subset of our total patient population from 2013 who went through the recovery room (N=6,138 for adults and N=3,042 for pediatric patients).

Page 8: Ophthalmology and Otolaryngology

Pain after surgery is one of

patients’ most common fears

and one of the most common

complaints after surgery. Our

goal is to have patients awaken

in the operating room and arrive

in the Post Anesthesia Care

Unit (PACU) or recovery room

as comfortable as possible.

Often, in the recovery room,

the patient may need more

analgesics prior to leaving.

Our goal is to ensure that every

patient leaves this area feeling

comfortable, whether going

home or to their hospital room.

We use a 10-point visual

analog score for adults to self-

report their pain. The scores

reported here reflect the adults’

perception of their own pain

assessment and their request

for pain medications.

For pediatric patients

old enough to assess their

own scores, we use the

same 10-point scale as used

for adults. For patients too

young to use the scale, the

nurses in the PACU use the

FLACC (Facial-Legs-Arms-

Crying-Comfortable) scale

that attributes behavioral

characteristics to a 10-point

pain scale. These are the scores

reported above for pediatric

patients.

6

Treatment Success of Pain in the PACU

Adult Pediatric

100

80

60

40

20

0Pain

treatedPain score < 3on discharge

Using 0-10 scales, our goal is to treat pain above a score of 3 and discharge patients from the PACU with scores less than 3. We report a sample subset of patients from 2013 (N=6,138 for adults and N=3,398 for pediatric patients.)

Perc

enta

ge

Page 9: Ophthalmology and Otolaryngology

Massachusetts Eye and Ear

O P H T H A L M O L O G Y D E P A R T M E N T

7

At the Mass. Eye and Ear/Harvard Medical School Department of

Ophthalmology, we have nearly two centuries of experience in

developing innovative approaches to treating eye disease and reducing

blindness worldwide. We founded subspecialty training in the areas of

cornea, retina and glaucoma, and have pioneered tools and treatments

for numerous diseases and conditions ranging from retinal detachment

to age-related macular degeneration to corneal scarring. Our patient-

centered core values focus on delivering the highest quality of care

through education, innovation and service excellence.

Page 10: Ophthalmology and Otolaryngology

Academic Affiliations

Harvard Medical School

Massachusetts General Hospital

Brigham and Women’s Hospital

Joslin Diabetes Center/ Beetham Eye Institute

Boston Children’s Hospital

Beth Israel Deaconess Medical Center

Veterans Affairs Boston Healthcare System

Veterans Affairs Maine Healthcare System

Cambridge Health Alliance

Aravind Eye Hospital, India

Eye and ENT Hospital of Fudan University, Shanghai, China

We Are:

• The primary teaching hospital of the Harvard Medical School Department of

Ophthalmology

• Home to Schepens Eye Research Institute, Howe Laboratory, and Berman-Gund

Laboratory for the Study of Retinal Degenerations

• Accelerating research and discovery through our multidisciplinary institutes and

subspecialty-based centers of excellence:

Institutes:

Ocular Genomics Institute

Ocular Regenerative Medicine Institute

Infectious Disease Institute

Centers of Excellence:

Age-related Macular Degeneration

Cornea

Diabetic Eye Disease

Glaucoma

Mobility Enhancement & Vision Rehabilitation

Ocular Oncology

Clinical Affiliations

• Massachusetts General Hospital (MGH) Department of Ophthalmology

- Mass. Eye and Ear provides comprehensive and subspecialty care and

inpatient consultations to MGH patients, including 24/7 emergency eye care

and trauma coverage. Mass. Eye and Ear clinicians also coordinate Neuro-

Ophthalmology and Burn Unit consultations at MGH.

- Mass. Eye and Ear staff screen MGH patients with or at high risk for diabetic

eye disease on a same-day basis in the main campus Retina Service and

through MGH’s Chelsea HealthCare Center teleretinal screening program.

- Mass. Eye and Ear’s new Same Day Service evaluates urgent and emergent

eye concerns of MGH patients as a less costly, more efficient alternative to

Emergency Department care.

• Joslin Diabetes Center/Beetham Eye Institute (BEI)

- Mass. Eye and Ear and BEI clinicians provide coordinated, integrated and

comprehensive care to patients throughout the region to prevent, diagnose

and treat patients with or at risk for diabetic eye disease.

8

Department of OphthalmologyMassachusetts Eye and Ear, Harvard Medical School

Page 11: Ophthalmology and Otolaryngology

For more information about

the Mass. Eye and Ear Quality

Program or the Department

of Ophthalmology, please

visit our website at

www.MassEyeAndEar.org.

• Brigham and Women’s Hospital (BWH)

- Mass. Eye and Ear provides comprehensive and subspecialty care and

inpatient consultations to BWH patients, including 24/7 emergency eye care

and trauma coverage.

- BWH patients may also receive a full range of ophthalmic care (including

Same Day Service urgent consultation and evaluations) at Mass. Eye and

Ear, Longwood, which is staffed by Mass. Eye and Ear clinicians with

participation from Joslin diabetes specialists.

• Children’s Hospital Ophthalmology Foundation

- Mass. Eye and Ear ophthalmologists provide subspecialty care in glaucoma

and cornea disease at Boston Children’s Hospital.

- Children’s Hospital clinicians staff the comprehensive Pediatric

Ophthalmology and Strabismus Service at Mass. Eye and Ear.

Ophthalmology Resources at Mass. Eye and Ear

• Highly skilled teams provide a full spectrum of primary and subspecialty

ophthalmic care.

• Our dedicated Eye Emergency Department is available 24/7.

• The Morse Laser Center provides advanced laser procedures using state-of-the-

art refractive, glaucoma, retinal and anterior segment lasers.

• The Ocular Surface Imaging Center enables rapid, non-invasive corneal biopsies.

• Our Electroretinography Service performs evaluations of patients referred for diagnosis,

prognosis, genetic counseling and treatment of retinal degenerative disorders.

• The David Glendenning Cogan Laboratory of Ophthalmic Pathology provides

enhanced diagnostic services in conjunction with the MGH Surgical Pathology Service.

• Our expanding Optometry Service provides screening and vision care in the

context of ophthalmic practice.

• The full service Contact Lens Service specializes in therapeutic fits, bandage and

specialty contact lenses.

• The Howe Library houses one of the most extensive ophthalmology research

collections in the world.

• The Medical Unit is staffed by Mass. Eye and Ear hospitalists and nurse practitioners.

• The Radiology Department houses a dedicated MRI/CT imaging suite.

• Our dedicated Social Work and Discharge Planning Department provides

information, counseling and referral services to patients and their families.

• The International Program assists patients with appointments, transportation,

accommodations and language translation.

• The Retina Service houses a dedicated ophthalmic ultrasound imaging suite.

9

Page 12: Ophthalmology and Otolaryngology

cornea

lens

pupil

iris

sclera retina

macula

optic nerve

vitreous

Data reported for 2010,

2011, 2012, and 2013

represent calendar years.

The 2009 data represent

12-month results as noted.

This bar graph shows the

number of ophthalmology

patients seen monthly by the

Mass. Eye and Ear Emergency

Department during the past

five calendar years. Throughout

this time, the Emergency

Department maintained a

high volume of ophthalmic

emergency visits, with an

average of 1,060 patients per

month in 2009, 1,050 in 2010,

1,091 in 2011, 1,304 in 2012

and 1,266 in 2013. Patient

volume generally increases

in the summer.

10

Eye Anatomy

Emergency Department: Ophthalmology Emergency Visits

1,800

1,500

1,200

900

600

300

0Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Num

ber

of v

isit

s

2009 (N = 12,717) 2010 (N = 12,603) 2011 (N = 13,086) 2012 (N = 15,650) 2013 (N = 15,189)

Month

Page 13: Ophthalmology and Otolaryngology

For the past five years, the

average ophthalmology visit

time in the Mass. Eye and Ear

Emergency Department was

better than the average national

and state visit times.

The Mass. Eye and Ear

Emergency Department

has a lower LWBS rate

when compared to

national benchmarks.

11

Emergency Department: Ophthalmology Visit Times

Emergency Department: Ophthalmology “Left Without Being Seen” (LWBS) Rate

10

9

8

7

6

5

4

3

2

1

0

The Mass. Eye and Ear Emergency Department reported a “left without being seen” (LWBS) rate of 1.1% (170/15,189) of patients for all ophthalmic emergency visits in 2013; unchanged from 2012. LWBS refers to those patients who present to an emergency department but leave before being seen by a physician. According to a 2009 report by the Society for Academic Emergency Medicine, the national LWBS rate is 1.7%.1 LWBS rates vary greatly between hospitals; a review of the literature suggests a national range of 1.7% to 4.4%.1-3

References: 1Pham JC et al. National study of patient, visit and hospital

characteristics associated with leaving an emergency department without

being seen: predicting LWBS. Academic Emergency Medicine 2009;

16(10): 949–955. 2Hsia RY et al. Hospital determinants of emergency

department left without being seen rates. Ann Emerg Med 2011; 58(1):

24-32.e3. 3Handel DA et al. The use of scripting at triage and its impact

on elopements. Acad Emerg Med 2010; 17(5): 495-500.

1.7% to 4.4% 1-3

Perc

enta

ge

1.1% 1.1%

2012 (N = 15,650)

2013 (N = 15,189)

National Benchmark

5

4

3

2

1

0

2.32.1

2.32.5

3.1

Massachusetts Average 4.06 Hours

Hou

rs

The average ophthalmology visit time in the Mass. Eye and Ear Emergency Department for 2013 was 3.1 hours. The visit time is defined as the total time from when the patient walked in the door at the Mass. Eye and Ear Emergency Department to when the patient walked out the door after seeing an ophthal-mologist. According to the 2010 Press Ganey Emergency Department Pulse Report, patients across the United States spent an average of four hours and seven minutes (4.12 hours) per ER visit. The Massachusetts (State) average visit time was 4.06 hours.

National Average 4.12 Hours

2009 (N = 12,717)* 2010 (N = 12,603)

2011 (N = 13,086) 2012 (N = 15,650)

2013 (N = 15,189)

*October 2008 – September 2009

Page 14: Ophthalmology and Otolaryngology

The photo on the left illustrates

the right eye of a patient who

sustained a nail gun injury at a

construction site. The nail was

removed and the wound closed;

there was no retina or lens

damage. After repair, the patient

did well and recovered to

20/20 vision.

Photo courtesy of

Matthew Gardiner, M.D.

In a retrospective review of 124

pediatric open-globe injuries

managed by the Eye Trauma

Service and/or Retina Service

between February 1999 and

April 2009, analysis showed a

median visual acuity at presen-

tation of “hand motions” (N =

123), and a final best-corrected

median visual acuity of 20/40

(N = 124) at ten months median

follow-up.1

12

Eye Trauma Surgery: Postoperative Median Vision

Eye Trauma Surgery

Bes

t-C

orre

cted

Vis

ual A

cuit

y

Preoperative Vision

Postoperative Vision

2010(N = 58)

2011 (N = 59)

2012 (N = 63)

2013(N = 68)

20/70

20/100

Light Perception

CountFingers

Hand Motions

Hand Motions

20/60

20/40

During the 2013 calendar year, 118 patients had open-globe repair by the Mass. Eye and Ear Eye Trauma Service for all surgical locations. Of these 118 patients, visual acuity at presentation was recorded in 117 patients. Visual acuity was not possible in one patient due to the patient’s mental status. At the time of publication, 68 patients had five months or more of follow-up, and only these individuals were analyzed for preoperative and postoperative vision. Patients with less than five months of follow-up were excluded from the analysis. During the 2013 calendar year, the median preoperative vision was “hand motions” and the median postoperative vision at the closest follow-up visit after five months was 20/40. Visual prognosis after ocular trauma is highly dependent on the severity of the initial trauma, but these data show that patients suffering from traumatic eye rupture can regain useful vision after surgery.

Reference: 1Shah AS, Andreoli MT, Andreoli CM, Heidary G.

“Pediatric open-globe injuries: A large scale, retrospective

review.” Poster presented at the 37th Annual Meeting of

the American Association for Pediatric Ophthalmology and

Strabismus, San Diego, California, USA, March 30-April 3,

2011. Abstract available in J AAPOS 2011; 15(1), e29.

20/15

20/20

20/25

20/30

20/40

20/50

20/60

20/70

20/80

20/100

20/200

20/400

Count Fingers

Hand Motions

Light Perception

No Light Perception

Page 15: Ophthalmology and Otolaryngology

0%0% 0% 0% 0%

Endophthalmitis rates after

eye trauma surgery performed

at Mass. Eye and Ear are the

lowest rates reported in the

country. Based on the Mass.

Eye and Ear experience and

the low percentage of cases

with endophthalmitis, we

recommend that institutions

adopt a standardized protocol

for treating open-globe

injuries and consider the

use of prophylactic systemic

antibiotics.1

13

Eye Trauma Surgery: Rates of Endophthalmitis After Open-Globe Repair

Eye Trauma Surgery: Time to Surgical Repair for Open-Globe Injuries

During calendar year 2013, 118 patients had open-globe repair by the Eye Trauma Service, and no cases of endophthalmitis were reported for any of the surgical locations. Similar results were reported for calendar years 2012, 2011, 2010, and 2009, as shown in the graph. Prior to 2009, data were collected on all open-globe injuries treated from January 2000 to July 2007. During this 7.5-year period, 675 open-globe injuries were treated at Mass. Eye and Ear. Intravenous vancomycin and ceftazidime were started on admission and stopped after 48 hours. Patients were discharged on topical antibiotics, corticosteroids, and cycloplegics. Of these 675 eyes, 558 had at least 30 days of follow-up (mean, 11 months). The overall percentage of endophthalmitis was 0.9% (or 5/558 cases).1 The standard Mass. Eye and Ear protocol for eye trauma (i.e., surgical repair by a dedicated trauma team and 48 hours of intravenous antibiotics) is associated with post-traumatic endophthalmitis in fewer than one percent of cases. A review of the literature suggests that endophthalmitis rates after open-globe repair around the world range from 2.6% to 17% and the United States National Eye Trauma Registry has reported an endophthalmitis rate of 6.9% after open-globe repair.1

Reference: 1Andreoli CM et al. Low rate of endophthalmitis in a large series of open

globe injuries. Am J Ophthalmol 2009; 147(4): 601-608.

During calendar year 2013, 118 patients suffered open-globe injuries that required urgent surgical repair by the Eye Trauma Service. Of those patients needing emergency surgery for ocular trauma, 117 (99.2%) were taken to the operating room within 24 hours of arrival at Mass. Eye and Ear or any of its surgical locations. In one case, the open-globe repair was performed within 29 hours of arrival. The delay over our internal protocol was due to operating room staff availability due to an emergent eight-hour craniotomy patient who presented first. The mean time from presentation at the Emergency Department to arrival in the operating room was 457.9 minutes, or 7.2 hours (range: 10 minutes to 29 hours). Ninety of the 118 (76.3%) patients were taken to the operating room in under 12 hours. Multiple studies suggest the benefit of repairing open-globe injuries within 12-24 hours, in particular for the prevention of endophthalmitis. In order to assure that we are able to always provide service within this timeframe, backup trauma surgeons are available to care for simultaneous injuries needing care here and at the other sites we cover.

25

20

15

10

5

0

Perc

enta

ge o

f en

doph

thal

mit

is

2.6% to 17%

2009 (N = 95)

2010 (N = 96)

2011 (N = 98)

2012 (N = 122)

2013 (N = 118)

International Benchmark

U.S. Rate 6.9%

100

80

60

40

20

0

2009 (N = 95)

2012 (N = 122)

2013 (N = 118)

Perc

enta

ge

< 12 hours < 24 hours

Time to Operating Room

66.0%

100.0%

69.7%76.3%

99.2%99.2%

Page 16: Ophthalmology and Otolaryngology

The Comprehensive

Ophthalmology and Cataract

Consultation Service at

Mass. Eye and Ear provides

a full spectrum of integrated

patient care, including annual

and diabetic eye exams,

prescriptions for eyeglasses,

continued management of a

wide range of eye problems,

and subspecialty referrals for

advanced care as needed.

The most common surgery

that we perform is cataract

extraction with intraocular lens

implantation.

Similar results were reported

for calendar years 2012, 2011,

and 2010. These results are

also consistent with an earlier

12-month period between July

2008 and June 2009, when data

collection began. For the past

five years, the Comprehensive

Ophthalmology and Cataract

Consultation Service has

consistently met or exceeded

international benchmarks for

successful cataract surgery.

14

Cataract Surgery: Achieving Target Refraction (Spherical Equivalent)

During the 2013 calendar year, the Comprehensive Ophthalmology and Cataract Consultation Service performed cataract surgery on 1,719 eyes at all surgical locations. This chart depicts the results of the 1,664 eyes that had at least one month of follow-up data. Of these 1,664 eyes, 95.7% (1,593/1,664) of cataract patients achieved within one diopter of target refraction after cataract surgery.

References: 1Kugelberg M, Lundström M.

Factors related to the degree of success in

achieving target refraction in cataract surgery:

Swedish National Cataract Register study. J

Cataract and Refract Surg 2008;34(11): 1935-

1939. 2Cole Eye Institute. Outcomes 2012. 3Lum F et al. Initial two years of experience

with the AAO National Eyecare Outcomes

Network (NEON) cataract surgery database.

Ophthalmology 2000; 107:691-697. 4Simon SS

et al. Achieving target refraction after cataract

surgery. Am J Ophthalmol 2014; 121:440-444.

normal lens cataract or cloudy

lens

Cataract Surgery

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

Dioptric difference from target refraction

71% to 94%1-4

2009 (N = 974)* 2010 (N = 1,285)

2011 (N = 1,250) 2012 (N = 1,437)

2013 (N = 1,664) International Benchmark

*July 2008-June 2009

< -2 -2 to < -1 -1 to +1 > +1 to +2 > +2

Page 17: Ophthalmology and Otolaryngology

The Mass. Eye and Ear

Comprehensive Ophthalmology

Service has excellent

intraoperative complication

rates compared to international

benchmarks.

15

Cataract Surgery: Intraoperative Complication Rates

Of the 1,719 cataract surgeries performed by the Comprehensive Ophthalmology and Cataract Consultation Service during the 2013 calendar year at all surgical locations, only 2.6% (44/1,719) had intraoperative complications. These results are displayed in the graph above. Similar results were reported in calendar year 2012, during which time only 2.5% (36/1,464) of cataract surgeries had intraoperative complications.

Mass. Eye and Ear 2013 Intraoperative Complication Rates:Descemet’s tear: 0.3% (4/1,719)Posterior capsule tear and/or vitreous loss: 1.6% (27/1,719) Dropped lens/retained lens fragment: 0.2% (4/1,719)Zonular dialysis: 0.5% (9/1,719)

International Benchmarks:1-5

Descemet’s tear: 0% - 0.9%Posterior capsule tear and/or vitreous loss: 0.3% - 4.4% Dropped lens/retained lens fragment: 0% - 1.7%Zonular dialysis: 0.1% - 1.2%

References: 1Greenberg PB et al. Prevalence and predictors of ocular complications associated with cataract surgery in United

States veterans. Ophthalmology 2011; 118(3): 507-514. 2Haripriya A et al. Complication rates of phacoemulsification and manual

small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg 2012; 38: 1360-1369. 3Pingree MF et al. Cataract

surgery complications in 1 year at an academic institution. J Cataract Refract Surg 1999; 25: 705-708. 4Ng DT et al. Intraoperative

complications of 1000 phacoemulsification procedures: a prospective study. J Cataract Refract Surg 1998; 24(10): 1390-1395. 5McKellar MJ, Elder MJ. The early complications of cataract surgery: is routine review of patients 1 week after cataract extraction

necessary? Ophthalmology 2001; 108(5): 930-935.

10

9

8

7

6

5

4

3

2

1

0

Perc

enta

ge o

f in

trao

pera

tive

com

plic

atio

ns

2012 (N = 1,464)

2013 (N = 1,719)

International Benchmark

Descemet’s tear PC tear and/or vitreous loss

Nuclear fragment/dropped fragment/

retained lens fragment

Zonular dialysis

0.2% 0.3%

1.7% 1.6%

0.3% 0.2% 0.2%0.5%

0% to 0.9%

0.3% to 4.4%

0% to 1.7%

0.1% to 1.2%

Page 18: Ophthalmology and Otolaryngology

The Retina Service at Mass.

Eye and Ear is one of the

largest subspecialty groups

of its kind in the country. Our

clinicians are highly skilled at

diagnosing and treating a full

range of ocular conditions,

including macular degeneration,

diabetic retinopathy, retinal

detachments, ocular tumors,

intraocular infections, and

severe ocular injuries.

16

Retina Surgery: Retinal Detachment and Retinal Detachment Repair

vitreousdetachment

subretinalfluid

retinaltear

retinaldetachment

scleral buckle

Retina Surgery: Single Surgery Success Rate for Primary Rhegmatogenous Retinal Detachment

Primary rhegmatogenous retinal detachment is one of the most common retinal conditions requiring surgical repair by the Mass. Eye and Ear Retina Service. During calendar year 2013, the Retina Service performed 489 surgical procedures to repair rhegmatogenous retinal detachments at all surgical locations. Techniques used included pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle surgery. Single surgery success rate of retinal reattachment was determined for primary, uncomplicated rhegmatogenous retinal detachments of less than one month duration for 220 eyes. In those 220 eyes, 76.4% (168/220) of the retinas were successfully reattached after one surgery at three months or greater of follow-up. Similar results were reported for calendar year 2012, during which time 80% (138/173) of retinas were successfully reattached after the first surgery. The Mass. Eye and Ear Retina Service single surgery success rate is comparable to international benchmarks reported in the literature, which show single surgery success rates ranging from 59% to 95% for primary rhegmatogenous retinal detachment repair.1-5 Benchmarks were determined from a literature review of studies that reported single surgery success rates for at least two of the three surgical techniques in this analysis (i.e., pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle).

References: 1Soni C et al. Surgical management of rhegmatogenous retinal detachment:

a meta-analysis of randomized controlled trials. Ophthalmology 2013; 120: 1440-1447. 2Feltgen N et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal

detachment study (SPR study): Risk assessment of anatomical outcome. SPR study report

no. 7. Acta Ophthalmol 2013:91:28-287. 3Adelman RA et al. Strategy for the management

of uncomplicated retinal detachments: the European Vitreo-Retinal Society retinal

detachment study report 1. Ophthalmology 2013; 120: 1804-1808. 4Sodhi A et al. Recent

trends in the management of rhegmatogenous retinal detachment. Surv Ophthalmol 2008;

53(1):50-67. 5Day S et al. One-year outcomes after retinal detachment surgery among

Medicare beneficiaries. Am J Ophthalmol 2010; 150(3):338-345.

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge o

f re

tina

s at

tach

ed

59.4% to 95%1-5

2012 (N = 173)

2013 (N = 220)

International Benchmark

80.0%76.4%

Page 19: Ophthalmology and Otolaryngology

With a 99.5% success rate for

primary rhegmatogenous retinal

detachment repair after one or

more surgeries, the Mass. Eye

and Ear Retina Service continues

to maintain high success rates

for this procedure. For the

past four years, the Retina

Service has consistently met

international benchmarks of

97% to 100% for successful

rhegmatogenous retinal

detachment repair.1-5

17

Retina Surgery: Final Retinal Reattachment Rate for Primary Rhegmatogenous Retinal Detachment

During calendar year 2013, the Mass. Eye and Ear Retina Service performed 489 surgical repairs to repair rhegmatogenous retinal detachments at all surgical locations. Surgical techniques included pneumatic retinopexy, pars plana vitrectomy, and/or scleral buckle surgery. This analysis includes the 284 procedures performed on 220 eyes with primary uncomplicated rhegmatogenous retinal detachments with at least three months of follow-up. Retinal reattachment was successfully achieved in 99.5% (219/220) of eyes with a primary rhegmatogenous retinal detachment during calendar year 2013. This success rate reflects eyes that had one or more surgeries, which may have included pars plana vitrectomy, scleral buckle, and pneumatic retinopexy. The smaller number of cases in calendar year 2010 may be attributable to a more stringent follow-up of having at least five months of data.

References: 1Han DP et al. Comparison of pneumatic retinopexy and scleral

buckling in the management of primary rhegmatogenous retinal detachment.

Am J Ophthalmol 1998; 126(5), 658-668. 2Avitabile T et al. A randomized

prospective study of rhegmatogenous retinal detachment cases treated with

cryopexy versus frequency-doubled Nd:YAG laser-retinopexy during episcleral

surgery. Retina 2004; 24(6), 878-882. 3Azad RV et al. Primary vitrectomy versus

conventional retinal detachment surgery in phakic rhegmatogenous retinal

detachment. Acta Ophthalmol Scand 2007; 85, 540-545. 4Sullivan PM et al.

Results of primary retinal reattachment surgery: a prospective audit. Eye 1997;

11, 869-871. 5Day S et al. One-year outcomes after retinal detachment surgery

among Medicare beneficiaries. Am J Ophthalmol 2010;150(3): 338–345.

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge o

f re

tina

s re

atta

ched

95.6%97.4% 98.4% 99.4% 99.5%

97% to 100%1-5

2009 (N = 160)* 2010 (N = 78)

2011 (N = 189) 2012 (N = 173)

2013 (N = 220)

International Benchmark

*March 2008-February 2009

Macular Hole Surgery: Single Surgery Success Rate at Three Months

During calendar year 2013, the Mass. Eye and Ear Retina Service performed 68 surgeries (including pars plana vitrectomy, membrane peel, and gas tamponade) for macular hole repair on 61 eyes at all surgical locations. The single surgery success rate for macular hole closure was determined for primary, uncomplicated macular holes of less than six months duration for a total of 33 eyes. Of the 33 eyes that underwent primary macular hole surgery in 2013, 31 eyes (93.9%) achieved surgical success with a single operation. Success was defined as any primary macular hole that remained fully closed at greater than three months after the first surgery. Similar results were reported in calendar year 2012, during which time 27 eyes (93.1%) with primary macular hole achieved surgical success with a single operation. A review of the literature suggests that single surgery success rates for macular hole surgery range from 89.8% to 93.0%.1-3

References: 1Wu D et al. Surgical outcomes of idiopathic macular hole repair with

limited postoperative positioning. Retina 2011; 31 (3), 609-611. 2Smiddy WE et al.

Internal limiting membrane peeling in macular hole surgery. American Academy of

Ophthalmology 2001; 108, 1471-1478. 3Guillaubey A et al. Comparison of face-down

and seated position after idiopathic macular hole surgery: a randomized clinical trial.

Am J Ophthalmol 2008; 146, 128-134.

89.8% to 93.0%1-3

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge o

f cl

osed

mac

ular

hol

es

93.1% 93.9%

2012 (N = 29)

2013 (N = 33)

National Benchmark

Page 20: Ophthalmology and Otolaryngology

(left) Photograph of

endophthalmitis

Photo courtesy of Lucy H. Young,

M.D., Ph.D., F.A.C.S.

Acute endophthalmitis is a

rare potential complication of

intravitreal injections. Mass.

Eye and Ear has excellent

intravitreal injection infection

rates compared to international

benchmarks.

18

During the 2013 calendar year, the Mass. Eye and Ear Retina Service performed 7,458 intravitreal injections at all service locations. Of these, no cases of acute endophthalmitis after intravitreal injection were identified. In order to identify cases of acute endophthalmitis, a retrospective review was performed of all consecutive eyes that underwent intravitreal injections from January 1, 2009 to December 31, 2013. During this five-year period, 21,050 intravitreal injections were performed by the Mass. Eye and Ear Retina Service. The overall incidence rate of endophthalmitis after intravitreal injection during this five-year period was 0.01% (three out of 21,050 injections).

References: 1Bhavsar AR et al. Risk of endophthalmitis

after intravitreal drug injection when topical antibiotics

are not required. Arch Ophthalmol 2009; 127(12): 1581-

1583. 2Englander M et al. Intravitreal injections at the

Massachusetts Eye and Ear Infirmary: analysis of treatment

indications and postinjection endophthalmitis rates. Br J

Ophthalmol 2013;97(4):460-465. 3Fileta JB et al. Meta-

analysis of infectious endophthalmitis after intravitreal

injection of anti-vascular endothelial growth factor agents.

Ophthalmic Surg Lasers Imaging Retina 2014; 45:143-149.

10

9

8

7

6

5

4

3

2

1

00.00% 0.05% 0.00% 0.03% 0.00%

Perc

enta

ge o

f en

doph

thal

mit

is

0.02% to 1.9%1

Retina Surgery: Rates of Endophthalmitis After Intravitreal Injection

2009 (N = 1,989)

2010 (N = 2,190)

2011 (N = 3,319)

2012 (N = 6,094)

2013 (N = 7,458)

International Benchmark

Retina Surgery

Page 21: Ophthalmology and Otolaryngology

(left) Localization of

choroidal melanoma with

transillumination. Tantalum

rings outline the tumor.

Photo courtesy of Evangelos S.

Gragoudas, M.D.

The Ophthalmic Oncology

Service at Mass. Eye and Ear,

under the direction of Evangelos

Gragoudas, M.D., is an

international referral center for

the diagnosis and treatment of

eye neoplasms.

Proton beam irradiation

was developed at Mass. Eye and

Ear in conjunction with a team

of radiotherapists from Mass.

General Hospital. In 1975, the

first proton beam irradiation

treatment was administered to a

Mass. Eye and Ear patient with

intraocular malignant melanoma.

19

Retina Surgery: Ophthalmic Oncology – Globe Perforation Rate from Surgery

Tumors located within the eye can be challenging to diagnose and treat effectively without causing damage to the eye, resulting in a loss of vision. Proton beam irradiation is one of the most effective therapies for treating intraocular tumors while minimizing visual loss from radiation complications.1 Perforation of the globe is a potential complication during tumor localization surgery. During calendar year 2013, the Ophthalmic Oncology Service at Mass. Eye and Ear performed tantalum ring surgery in preparation for proton beam irradiation on 101 eyes. Zero cases of globe perforation from surgery were reported. There were also no cases of globe perforation reported in 2012.

Reference: 1Gragoudas ES. Proton beam irradiation of uveal melanomas:

the first 30 years. The Weisenfeld Lecture. Invest Ophthalmol Vis Sci.

2006 Nov;47(11):4666-73.

10

9

8

7

6

5

4

3

2

1

00% 0%

Perc

enta

ge o

f gl

obe

perf

orat

ions

2012 (N = 99)

2013 (N = 101)

Retina Surgery:Ophthalmic Oncology

Page 22: Ophthalmology and Otolaryngology

P R E S S U R E

Glaucoma Surgery: Trabeculectomy and Tube Shunt Infection Rates

The most common incisional surgeries performed by the Mass. Eye and Ear Glaucoma Consultation Service are trabeculectomy surgery and tube shunt surgeries at all surgical locations. During the 2013 calendar year, the Glaucoma Consultation Service performed a total of 307 trabeculectomy and tube shunt surgeries. These surgeries included trabeculectomy surgery (with or without previous scarring) on 152 eyes and tube shunt surgeries (primary or revision) on 155 eyes. These procedures may have been combined with other procedures, such as cataract extraction. Zero cases of endophthalmitis were reported, and similar rates have been reported since data collection began in calendar year 2010. With trabeculectomy and tube shunt infection rates, complete success is defined as a zero percent infection rate per year. A review of the literature suggests that trabeculectomy and tube shunt infection rates range from 0.12% to 8.33%.1

Reference: 1Ang GS et al. Postoperative infection in penetrating versus non-

penetrating glaucoma surgery. Br J Ophthalmol 2010; 94(12): 1571-1576.

25

20

15

10

5

00% 0% 0% 0%

Perc

enta

ge o

f in

fect

ions

0.12% to 8.33% 1

2010 (N = 245)

2011 (N = 270)

2012 (N = 323)

2013 (N = 307)

International Benchmark

Glaucoma is a group of

disorders that affect the optic

nerve, which transmits image

signals from the retina to the

brain. In glaucoma, damage to

the optic nerve results in vision

loss. The main risk factor for

glaucoma is elevated pressure

in the eye. Members of the

Mass. Eye and Ear Glaucoma

Consultation Service are trained

in the most advanced laser

and surgical procedures to

treat glaucoma. Our specialists

treat patients with all forms

and stages of glaucoma—even

those with advanced disease—

and often receive referrals of

difficult cases.

For the past four years, the

Mass. Eye and Ear Glaucoma

Consultation Service has

maintained excellent

trabeculectomy and tube shunt

infection rates compared to

international benchmarks.

20

Glaucoma Surgery

Page 23: Ophthalmology and Otolaryngology

The Mass. Eye and Ear

Glaucoma Consultation

Service continues to maintain

very favorable intraoperative

complication rates compared

to international benchmarks.

21

Trabeculectomy and Glaucoma Implant Surgery: Intraoperative Complications

10

8

6

4

2

0Conjunctival

tear/buttonholeHyphema Scleral flap

traumaVitreous loss/

prolapseSuprachoroidalhemorrhage

Scleral perforation

Of the 217 cases of trabeculectomy surgery or glaucoma implant surgery performed by the Glaucoma Consultation Service during the 2013 calendar year at all surgical locations, 98.6% (214/217) of patients had no intraoperative complications. The cases analyzed include only those trabeculectomy or implant surgeries not combined with cataract or keratoprosthesis procedures. Similar results were reported for calendar year 2012, 2011, and 2010, during which time 97.2% (314/323), 99.6% (269/270) and 95.5% (234/245) of patients had no intraoperative complications, respectively. These results are also consistent with an earlier 24-month period between July 2007 and June 2009 when 97.1% (299/308) of eyes had no intraoperative complications. Mass. Eye and Ear 2013 complication rates:Conjunctival tear/buttonhole: 1.4%Hyphema: 0%Scleral flap trauma: 0%Vitreous loss (vitreous prolapse): 0%Suprachoroidal hemorrhage: 0%Scleral perforation: 0%

The 217 cases evaluated included:79 trabeculectomies without scarring14 trabeculectomies with previous scarring105 primary tube surgeries19 tube revisions

References: 1Barton K et al. The Ahmed Baerveldt Comparison Study: methodology, baseline patient characteristics, and

intraoperative complications. Ophthalmology 2011; 118(3): 435-442. 2Jampel HD et al. Perioperative complications of

trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). Am J Ophthalmol 2005; 140(1): 16-22. 3Gedde SJ

et al. Surgical complications in the Tube Versus Trabeculectomy Study during the first year of follow-up. Am J Ophthalmol 2007;

143(1): 23-31. 4Christakis PG et al. The Ahmed Versus Baerveldt Comparison Study: design, baseline patient characteristics, and

intraoperative complications. Ophthalmology 2011; 118(11): 2172-2179.

International benchmarks:1-4

Conjunctival tear/buttonhole: 1.1% - 3.0%Hyphema: 1.0% - 8.0%Scleral flap trauma: 0.7%Vitreous loss (vitreous prolapse): 1.0%Suprachoroidal hemorrhage: 0% - 1.0%Scleral perforation: 0% - 3.0%

Perc

enta

ge o

f in

trao

pera

tive

com

plic

atio

ns

2007-2009 (N = 308)* 2010 (N = 245)

2011 (N = 270) 2012 (N = 323)

2013 (N = 217) International Benchmark

*July 2007-June 2009

1.1% to 3%

1% to 8%

0.7%1% 0% to 1%

0% to 3%

Page 24: Ophthalmology and Otolaryngology

Preoperative and postoperative

intraocular pressure (IOP)

measurements were taken

using the Tono-Pen (Reichert,

Buffalo, NY) prior to the laser

procedure and within one

hour of the conclusion of

the laser procedure. For this

analysis, if multiple pressure

readings were taken, the

average pressure reading was

used when calculating the

IOP difference (postoperative

minus preoperative). All

measurements were taken

by a certified ophthalmic

technician. All patients received

either brimonidine 0.1% or

0.15% or apraclonidine 0.5%

before the laser procedure and

prednisolone 1% after the

procedure.

22

Glaucoma Laser Surgery: Postoperative Intraocular Pressure (IOP) Spikes

During calendar year 2013, the Glaucoma Consultation Service performed anterior segment laser procedures on 742 eyes at all laser locations. Of the 742 eyes, this analysis includes the 587 eyes that had laser peripheral iridotomies (210), capsulotomies (65) and laser trabeculoplasties (312). Of the 312 laser trabeculoplasties, 64 were argon laser trabeculoplasties (ALT) and 248 were selective laser trabeculoplasties (SLT). Similar results were reported in calendar year 2012, when data collection began.

≥5 mm Hg ≥10 mm Hg Mass. Eye Mass. Eye and Ear International1-8 and Ear International1,3-4,6-9

Laser peripheral iridotomy: 19% 0% - 35% 5.5% 0%

Capsulotomy: 7.7% 5.7% - 13% 0% 0.02% - 4%

Laser trabeculoplasty: 11.2% 7% - 10.3% 1.9% 3%

Overall: 13.6% 0% - 31.7% 3.1% 0% - 9.8%

References: 1Chevier RL et al. Apraclonidine 0.5% versus brimonidine 0.2% for the control of intraocular pressure elevation following

anterior segment laser procedure. Ophthalmic Surg Lasers 1999; 30(1): 199-204. 2Yuen NSY et al. Comparing brimonidine 0.2% to

apraclonidine 1.0% in the prevention of intraocular pressure elevation and their pupillary effects following laser peripheral iridotomy.

Jpn J Ophthalmol 2005; 49(1): 89-92. 3Yeom HY et al. Brimonidine 0.2% versus brimonidine purite 0.15%: prophylactic effect on

IOP elevation after Nd:YAG laser posterior capsulotomy. Journal of Ocular Pharm. & Therapeutics 2006; 22(1): 176-181. 4Collum RD

Jr. et al. The effect of apraclonidine on the intraocular pressure of glaucoma patients following Nd:YAG laser posterior capsulotomy.

Ophthalmic Surgery 1993: 24(9): 623-626. 5Lai JSM et al. Five-year follow-up of selective laser trabeculoplasty in Chinese eyes. Clin

Experiment Ophthalmol 2004; 32(1): 368-372. 6Francis BA et al. Selective laser trabeculoplasty as a replacement for medical therapy

in open-angle glaucoma. Am J Ophthalmol 2005; 140:524–525. 7Chen TC et al. Brimonidine 0.2% versus apraclonidine 0.5% for

prevention of intraocular pressure elevations after anterior segment laser surgery. Ophthalmology 2001;108:1033-103. 8Chen TC.

Brimonidine 0.15% versus apraclonidine 0.5% for prevention of intraocular pressure elevation after anterior segment laser surgery. J

Cataract Refractive Surg 2005; 31(9): 1707–1712. 9Hong C et al. Effect of apraclonidine hydrochloride on acute intraocular pressure

rise after argon laser iridotomy. Korean J Ophthalmol 1991; 5(1): 37-41.

40

30

20

10

0

≥5 mm Hg ≥10 mm Hg

Perc

enta

ge o

f IO

P sp

ikes

Laser peripheral iridotomy

Laser peripheral iridotomy

Capsulotomy CapsulotomyLaserTrabeculoplasty

(ALT/SLT)

LaserTrabeculoplasty

(ALT/SLT)

Overall Overall

0% to 35%

5.7% to 13%

7% to 10.3%

0% 3%

0% to 31.7%

0% to 9.8%

0.02% to 4%

2012 (N = 556) 2013 (N = 587) International Benchmark

Page 25: Ophthalmology and Otolaryngology

In summary, the Mass. Eye

and Ear Glaucoma Consultation

Service achieves excellent

surgical success with

trabeculectomy, and

reoperation rates are low.

23

Glaucoma Surgery: Mitomycin C Trabeculectomy Reoperation Rates at One Month and Six Months

10

9

8

7

6

5

4

3

2

1

0

Trabeculectomy is the gold standard incisional surgery for glaucoma patients who require surgery. There were 93 mitomycin C trabeculectomy surgeries (with or without scarring) performed by the Glaucoma Consultation Service for the 2013 calendar year at all surgical locations. Reoperation rates were calculated at the one-month and six-month postoperative time period. Reoperations were defined as glaucoma procedures required for further intraocular pressure lowering (i.e., repeat trabeculectomy, tube shunt surgery, diode cyclophotocoagulation, etc.). One patient was lost to follow-up at the six-month time period. The Mass. Eye and Ear Glaucoma Consultation Service reoperation rate for mitomycin C trabeculectomy surgery at one month was 2.2% (two patients underwent bleb revisions) and at six months was 4.3% (the aforementioned two bleb revisions, and two tube shunt surgeries). To the best of our knowledge, published data on one- and six-month reoperation rates are lacking; thus, our rates are good internal benchmarks to continue to follow.

Perc

enta

ge o

f re

oper

atio

ns

4.3%

One Month Postoperative (N = 93)

Six Months Postoperative (N = 92)

2.2%

Page 26: Ophthalmology and Otolaryngology

1.

3.

2.

4.

Refractive surgery, commonly

known as laser vision

correction, is a term given

to surgical procedures

designed to correct certain

visual problems such as

myopia (nearsightedness),

hyperopia (farsightedness),

and astigmatism. The Mass.

Eye and Ear Cornea and

Refractive Surgery Service

offers a number of refractive

procedures, the most common

of which are laser-assisted

in situ keratomileusis

(LASIK) and photorefractive

keratectomy (PRK).

During the 2013 calendar

year, 248 of the 263 eyes

that had LASIK surgery had

sufficient follow-up data for

analysis. Sufficient follow-

up was defined as at least

one month of follow-up for

myopia and three months

follow-up for hyperopia.

In calendar year 2013,

the overall LASIK success

rate for achieving within 0.5

diopters of target refraction

for myopia and hyperopia

was 88.7% (220/248 eyes).

24

Refractive Surgery (Laser Vision Correction)

Refractive Surgery — LASIK for Myopia: Achieving Target Refraction (Spherical Equivalent)

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge w

ithi

n 0.

5 di

opte

rs o

f ta

rget

ref

ract

ion

During the 2013 calendar year, 212 of the 248 eyes that had LASIK surgery were myopic and had at least one month follow-up data for analysis. The LASIK success rate for myopia at one month was 90.1% (191/212 eyes) for calendar year 2013. Benchmark data from FDA trials for LASIK for myopia showed that 71.6% of eyes resulted in a refractive error within 0.5 diopters of the intended target correction.1 Further review of the literature suggests that after LASIK surgery for myopia, approximately 70% to 83% of eyes achieve within 0.5 diopters of the intended target correction.1-2 For the past five years, the Mass. Eye and Ear Cornea and Refractive Surgery Service has consistently exceeded international benchmarks for successful LASIK surgery for myopia.

References: 1Bailey MD, Zadnick K. Outcomes of LASIK for

myopia with FDA-approved lasers. Cornea 2007; 26(3),

246–254. 2Yuen LH et al. A 10-year prospective audit of LASIK

outcomes for myopia in 37,932 eyes at a single institution in

Asia. Ophthalmology 2010; 117(6): 1236–1244.

86.9% 86.9% 88.1% 89.3% 90.1%

70% to 83%1-2

2009 (N = 289)* 2010 (N = 252)

2011 (N = 260) 2012 (N = 271)

2013 (N = 212) International Benchmark

*July 2008-June 2009

Page 27: Ophthalmology and Otolaryngology

The Mass. Eye and Ear Cornea

and Refractive Surgery Service

continues to maintain a high

overall success rate for LASIK

surgery for myopia.

25

Refractive Surgery — LASIK for Different Degrees of Myopia: Achieving Target Refraction (Spherical Equivalent)

In calendar year 2013, 212 of the 248 eyes had LASIK surgery for myopia, and the success rates based on the degree of myopia are graphed here. LASIK for low myopia was performed on 80 eyes, and of these, 95% (76/80 eyes) were successful. For the 116 eyes with moderate myopia, 87.9% (102/116 eyes) were successful; and for the 16 eyes with high myopia, 81.3% (13/16 eyes) achieved within 0.5 diopters of target refraction at one month follow-up. Similar results were reported for the 2012, 2011 and 2010 calendar years, during which time the success rate for low myopia was 90.4% (75/83 eyes), 97.3% (71/73 eyes) and 91.5% (86/94 eyes), respectively. Moderate myopia success rates were consistent for 2012, 2011 and 2010 with 91.2% (145/159 eyes), 82.1% (128/156 eyes) and 85.4% (105/123 eyes), respectively. Results for LASIK for high myopia ranged from 75.9% (22/29 eyes) in 2012, to 96.8% (30/31 eyes) in 2011 and 80% (28/35 eyes) in 2010. These results are also consistent with the 12-month period between July 2008 and June 2009, which had success rates for low, moderate and high myopia of 86.1% (93/108 eyes), 87.8% (145/165) and 81.3% (13/16 eyes), respectively.

100

90

80

70

60

50

40

30

20

10

0Low Myopia

less than 3 diopters of sphereModerate Myopia

3 to <7 diopters of sphereHigh Myopia

7 to 10 diopters of sphere

Perc

enta

ge w

ithi

n 0.

5 di

opte

rs o

f ta

rget

ref

ract

ion

2009 (N = 289)* 2010 (N = 252) 2011 (N = 260) 2012 (N = 271) 2013 (N = 212)

*July 2008-June 2009

86.1

91.5

97.3

90.4

95.0

87.885.4

82.1

91.287.9

81.3 80.0

96.8

75.9

81.3

Page 28: Ophthalmology and Otolaryngology

26

Refractive Surgery — LASIK for Hyperopia: Achieving Target Refraction (Spherical Equivalent)

79.3%85.0%

77.8%

68.0%

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge w

ithi

n 0.

5 di

opte

rs o

f ta

rget

ref

ract

ion

Of the 51 eyes that had LASIK surgery for hyperopia during the 2013 calendar year, 36 had three months or more of follow-up data for analysis. The overall 2013 LASIK success rate for achieving within 0.5 diopters of target refraction was 80.6% (29/36 eyes) for hyperopia. A review of the literature suggests that the success rate for achieving within 0.5 diopters of the intended target correction after LASIK for hyperopia ranges between 66.7% and 91%.1-3

References: 1Alio JL et al. Laser in situ keratomileusis for high

hyperopia (>5.0 diopters) using optimized aspheric profiles:

efficacy and safety. J Cataract Refract Surg 2013; 39: 519-527. 2Keir NJ et al. Outcomes of wavefront-guided laser in situ

keratomileusis for hyperopia. J Cataract Refract Surg 2011;

37(5): 886–893. 3Cole Eye Institute. Outcomes 2012.

80.6%

66.7% to 91%1-3

2009 (N = 40)* 2010 (N = 29)

2011 (N = 25) 2012 (N = 36)

2013 (N = 36) International Benchmark

*July 2008-June 2009

Failed Graft 62.1%

For the past four years, the

Mass. Eye and Ear Cornea and

Refractive Surgery Service has

maintained low enhancement/

retreatment rates when

compared to international

benchmarks.

For the past five years, the

Mass. Eye and Ear Cornea

and Refractive Surgery Service

has consistently met the

international benchmarks

for successful LASIK surgery

for hyperopia.

Refractive Surgery — LASIK: Enhancement/Retreatment Rates at Six Months Follow-up

50

45

40

35

30

25

20

15

10

5

0

Of the 248 eyes that had LASIK surgery for myopia or hyperopia during the 2013 calendar year, 5.2% (13/248) had an enhancement/retreatment procedure within six months. Similar results have been reported since calendar year 2010, when data collection for enhancement/retreatment rates began. LASIK retreatment rates of between 3.8% and 29.4% have been reported in the literature.1-3

References: 1Bragheeth MA et al. Re-treatment after laser

in situ keratomileusis for correction of myopia and myopic

astigmatism. Br J Ophthalmol 2008; 92(11): 1506-1511. 2Yuen LH et al. A 10-year prospective audit of LASIK

outcomes for myopia in 37,932 eyes at a single institution

in Asia. Ophthalmology 2010; 117(6): 1236-1244. 3Alio JL

et al. Laser in situ keratomileusis for high hyperopia (>5.0

diopters) using optimized aspheric profiles: efficacy and

safety. J Cataract Refract Surg 2013; 39: 519-527.

3.8% to 29.4% 1-3

LASI

K r

etre

atm

ents

/enh

ance

men

ts

7.4% 6.8%5.2%

2010 (N = 296) 2011 (N = 285)

2012 (N = 307) 2013 (N = 248)

International Benchmark

2.7%

Page 29: Ophthalmology and Otolaryngology

(left) Photograph of

keratoprosthesis (KPro)

Photo courtesy of

Claes Dohlman, M.D., Ph.D.

27

Cornea Surgery:Keratoprosthesis (KPro)

The Boston keratoprosthesis (KPro) is an artificial cornea developed at Mass. Eye and Ear by Claes Dohlman, M.D., Ph.D. and colleagues. Dr. Dohlman is former Chief and Chair of the Department of Ophthalmology, and currently Emeritus Professor of Ophthalmology at Harvard Medical School. In development since the 1960s, the KPro received FDA clearance in 1992 and achieved European Conformity (CE) Mark approval in June 2014. It is the most commonly used artificial cornea in the U.S. and world-wide, with more than 10,000 implantations to date. The KPro is reserved for patients blinded by corneal disease and for whom a standard corneal transplant is not a viable option.1

N = 29

Cornea Surgery:Surgical Indications for Keratoprosthesis (KPro)

Thirty-seven patients received the type 1 Boston keratoprosthesis (KPro) during calendar year 2013. Of these 37 patients, 29 (78.3%) received a KPro for the first time and are included in this analysis. Similar data were reported for calendar year 2012, during which time 36 patients received a type 1 KPro, with 25 of them having a primary type 1 KPro with at least three months of follow-up data. Indications for KPro surgery included failed corneal grafts (18/29, 62.1%), aniridic keratopathy (6/29, 20.7%), corneal neovascularization (3/29, 10.3%), mucus membrane pemphigoid (1/29, 3.4%), and perforated cornea (1/29, 3.4%). Nine patients (9/29, 31%) received the KPro as a primary procedure. Two aniridic eyes had prior failed grafts but were only graphed in the aniridic keratopathy category.

Reference: 1Ament JD et al. Cost-effectiveness

of the Boston keratoprosthesis. Am J Ophthalmol

2010; 149: 221-228.

Failed Graft 62.1%

Mucus MembranePemphigoid

3.4%

Corneal Neovascularization10.3%

Perforated Cornea3.4%

AniridicKeratopathy20.7%

Page 30: Ophthalmology and Otolaryngology

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

28

Cornea Surgery:Visual Outcomes of Keratoprosthesis (KPro)

Cornea Surgery:Keratoprosthesis (KPro) Retention Rates

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

Of the 29 primary type 1 Boston keratoprosthesis (KPro) surgeries in calendar year 2013 for which three months of follow-up data were available, 100% of patients retained the KPro at three months. Similar results were reported for calendar years 2011 and 2012, during which time, 100% of patients retained the KPro at three months. According to the literature, expected retention rates range from 90.5% to 95% of patients.1-2

References: 1Kang JJ et al. Visual outcomes of Boston keratoprosthesis

implantation as the primary penetrating corneal procedure. Cornea 2012;

0(0): 1-5. 2Zerbe BL et al. Results from the multicenter Boston type I

keratoprosthesis study. Ophthalmology 2006; 113(1): 1779.e1-1779.e7.

100% 100% 100%

90.5% to 95%1-2

2011 (N = 27)

2012 (N = 25)

2013 (N = 29)

National Benchmark

2011 (N = 27)

2012 (N = 25)

2013 (N = 29)

National Benchmark

During calendar year 2013, 29 patients underwent primary type 1 Boston keratoprosthesis (KPro) surgery for the first time and had at least three months of follow-up data available for analysis. Of these 29 patients, 22 (76%) achieved 20/200 vision or better at any point within the three-month postoperative period or beyond. This is comparable to national benchmarks of 56% to 89% reported in the literature.1-3

Seven patients did not achieve a postoperative vision of 20/200 or better, and in each case, the patient had pre-existing severe retinal disease or advanced glaucoma, which limited the visual acuity. References: 1Kang JJ et al. Visual outcomes of Boston keratoprosthesis

implantation as the primary penetrating corneal procedure. Cornea 2012;

0(0): 1-5. 2Zerbe BL et al. Results from the multicenter Boston type I

keratoprosthesis study. Ophthalmology 2006; 113(1): 1779.e1-1779.e7. 3Greiner MA et al. Longer-term vision outcomes and complications with

the Boston type 1 keratoprosthesis at the University of California, Davis.

Ophthalmology 2011; 118: 1543-1550.

56% to 89%1-3

20/200or better

66.7%

84%

76%

For the past three years, the

Mass. Eye and Ear Cornea

and Refractive Surgery Service

has consistently met national

benchmarks for visual outcomes

following keratoprosthesis

(KPro) surgery.

KPro retention rates at three

months were 100% in 2011,

2012, and 2013.

Page 31: Ophthalmology and Otolaryngology

(left) The photos illustrate

the before and after of an

eye that underwent

penetrating keratoplasty (PK)

for pseudomonas keratitis

in a prior radial keratotomy

incision.

Photo courtesy of

James Chodosh, M.D., M.P.H.

29

Cornea Surgery: Penetrating Keratoplasty

The proportion of

keratoplasties performed in

partial thickness fashion by

surgeons of the Mass. Eye

and Ear Cornea Service

increased from 10% in 2009

to 67% in 2013.

Cornea Surgery: Distribution of Full-Thickness and Partial-Thickness Keratoplasty

During the 2013 calendar year, the Mass. Eye and Ear Cornea Service performed 256 keratoplasty procedures at all surgical locations; of these, 134 (52.3%) were full-thickness and 122 (47.7%) were partial-thickness, or lamellar. Fifty penetrating (full-thickness) keratoplasties (PKs) were done in combination with retinal, glaucoma or KPro procedures and were excluded from the distribution analysis. Additionally, there were 23 therapeutic PKs done for active infection or non-healing ulcers and these were also excluded from the analysis. This left 61 PKs for inclusion in the distribution analysis compared to 122 partial-thickness procedures: 107 Descemet’s stripping endothelial keratoplasties (DSEK) and 15 deep anterior lamellar keratoplasties (DALK).

N = 183

Penetrating Keratoplasty (PK)33.3%

Deep AnteriorLamellar Keratoplasty(DALK)8.2%

Descemet’sStripping Endothelial Keratoplasty (DSEK)

58.5%

Page 32: Ophthalmology and Otolaryngology

30

In 2013, the most common

indications for elective full-

thickness keratoplasties (PKs)

at Mass. Eye and Ear were

failed corneal graft (41.4%),

corneal scar (24.1%), and

keratoconus (15.5%).

For the past five years, the

Mass. Eye and Ear PK surgery

success rates have consistently

met or exceeded international

benchmarks.1-2

Cornea Surgery: Surgical Indications for Penetrating Keratoplasty (PK)

During the 2013 calendar year, 134 penetrating (full-thickness) keratoplasties (PKs) were performed by the Mass. Eye and Ear Cornea and Refractive Surgery Service at all surgical locations. The current analysis includes only those elective PKs for which up to three months of follow-up data were available and which were not done in combination with retinal, glaucoma or KPro procedures. This left 58 (43.3%) elective PKs for analysis for calendar year 2013. These 58 elective PKs included first-time grafts in uninflamed host beds as well as those performed in eyes at high risk of rejection, including those with extensive corneal neovascularization and/or eyes with a failed corneal graft. Indications for elective PKs included failed corneal graft (24/58, 41.4%), corneal scar (14/58, 24.1%), keratoconus (9/58, 15.5%), Fuchs’ dystrophy (4/58, 6.9%), bullous keratopathy (3/58, 5.2%), corneal edema (2/58, 3.5%), corneal dystrophy (1/58, 1.7%), and neurotrophic keratopathy (1/58, 1.7%).

N = 58

Corneal Dystrophy1.7%

NeurotrophicKeratopathy

1.7%

Corneal Edema3.5%

BullousKeratopathy5.2%

Keratoconus15.5%

Corneal Scar24.1%

Failed Corneal

Graft41.4% Fuchs’

Dystrophy6.9%

Cornea Surgery: Clear Corneal Grafts after Penetrating Keratoplasty (PK) Surgery at Three Months Follow-up

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge o

f gr

afts

cle

ar f

or e

lect

ive

PK

Fifty-eight of the 134 PKs (full-thickness) performed in 2013 at all surgical locations were elective with up to three months follow-up analysis. Of these elective PKs, 57 (98.3%) achieved surgical success, which is defined as a graft at three months follow-up with minimal (to no) clinical edema and which possesses clarity sufficient to permit the examiner to have an unencumbered view of the interior of the eye including iris details.

References: 1Vail A et al. Corneal graft survival and visual

outcome: a multicenter study. Ophthalmology 1994;

101(1):120-127. 2Price MO et al. Risk factors for various

causes of failure in initial corneal grafts. Arch Ophthalmol

2003; 121:1087-1092.

93.0% 92.8%98.3% 98.3%

92.5% to 95%1-2

96.8%

2009 (N = 126)* 2010 (N = 71)

2011 (N = 69) 2012 (N = 60)

2013 (N = 58) International Benchmark

*July 2008-July 2009

Page 33: Ophthalmology and Otolaryngology

Oculoplastic Surgery: Reoperation Rate for External Dacryocystorhinostomy (Ex-DCR) Surgery at Six Months Follow-up

25

20

15

10

5

0

Reo

pera

tion

rat

e af

ter

exte

rnal

DC

R s

urge

ry (

%)

During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed external dacryocystorhinostomy (Ex-DCR) procedures on 73 eyes of 65 patients at all surgical locations. Seventeen eyes of 16 patients were excluded for pre-existing ocular conditions such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), and benign tumors. This analysis includes the remaining 56 eyes of 49 patients who underwent primary Ex-DCR in 2013 for primary acquired nasolacrimal duct obstruction (NLDO). Of these eyes, 1.8% (1/56) required a second procedure within six months in order to achieve surgical success. Similar results were reported for calendar year 2012, during which time there were no reoperations within six months of primary Ex-DCR. Ex-DCR is often considered the standard of care for NLDO. A review of the literature suggests that 7.8% - 12.5% of patients require reoperation following primary Ex-DCR for primary acquired NLDO.1-3

References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with

nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003; 110:78-84. 2Karim R et al. A comparison of external and endoscopic dacryocystorhinostomy

for acquired nasolacrimal duct obstruction. Clinical Ophthalmology 2011; 5:979-

989. 3Ben Simon GJ et al. External versus endoscopic dacryocystorhinostomy for

acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology

2005; 112:1463-1468.

7.8% to 12.5%1-3

2012 (N = 70)

2013 (N = 56)

International Benchmark

0.0%

1.8%

31

Oculoplastic Surgery: Dacryocystorhinostomy (DCR) Lacrimal Bypass Surgery

For the past two years, the

Mass. Eye and Ear Ophthalmic

Plastic Surgery Service has

maintained a low reoperation

rate for Ex-DCR surgeries

compared to international

benchmarks.

Dacryocystorhinostomy (DCR)

is a surgery that aims to

improve tear drainage from the

lacrimal sac to the nose.

Lacrimal gland

Canaliculus

Lacrimal sac

DCR ostium site

Nasolacrimal duct

Page 34: Ophthalmology and Otolaryngology

2% to 11%1-4

Oculoplastic Surgery: Reoperation Rate for Lid Surgeries at Six Months Follow-up

32

In contrast to conventional

external DCR (Ex-DCR),

En-DCR is a minimally invasive

procedure that is possible due

to technological advances in

instruments of rhinologic surgery.

This analysis includes En-DCR

procedures done in patients

with underlying sinus disease or

other intranasal abnormality such

as significant septal deviation.

Approximately half of all En-DCR

procedures reported for 2013

were done in collaboration with

rhinologists from the Mass. Eye

and Ear/Harvard Medical School

Department of Otolaryngology.

The Mass. Eye and Ear

Ophthalmic Plastic Surgery

Service continues to have one

of the lowest reoperation rates

for eyelid surgeries compared

to international benchmarks.

Oculoplastic Surgery: Reoperation Rate for Endoscopic Dacryocystorhinostomy (En-DCR) Surgery at Six Months Follow-up

25

20

15

10

5

0

Reo

pera

tion

rat

e af

ter

lid s

urge

ry (

%)

During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed upper-lid blepharoplasty and/or ptosis repair surgeries on 574 eyelids in 341 patients at all surgical locations. Of these eyelids, only 3.1% (18/574) required a second procedure within six months in order to achieve surgical success. Similar results were reported for calendar years 2011 and 2012, during which time 2.6% (11/416) and 1.7% (8/467) of eyelids, respectively, required a second procedure within six months. These results are also consistent with an earlier 12-month period from March 2008 to February 2009 when 2.9% (10/343) of eyelids required a reoperation. A review of the literature suggests that reoperation rates after eyelid surgery range from 2.6% to 8.7%.1-2

References: 1Scoppettuolo E et al. British Oculoplastic Surgery

Society (BOPSS) National Ptosis Survey. Br J Ophthalmol 2008;

92(8): 1134–1138. 2Melicher J, Nerad JA. Chapter 29: Ptosis

surgery failure and reoperation. In: Cohen AJ, Weinberg DA,

eds. Evaluation and management of blepharoptosis. New York:

Springer; 2011, 269-274.

2.6% to 8.7%1-2

2009 (N = 343)* 2011 (N = 416)

2012 (N = 467) 2013 (N = 574)

International Benchmark

*March 2008-February 2009

2.9% 2.6%1.7%

3.1%

25

20

15

10

5

0

Reo

pera

tion

rat

e af

ter

endo

scop

ic D

CR

sur

gery

(%

)

During the 2013 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed endoscopic dacryocystorhinostomy (En-DCR) procedures on 41 eyes of 37 patients at all surgical locations. Twenty-three eyes of 20 patients were excluded for pre-existing ocular conditions such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), and benign tumors. Procedures involving laser DCR were also excluded. This analysis includes the remaining 18 eyes of 17 patients who underwent primary En-DCR in 2013 for primary acquired nasolacrimal duct obstruction. Of these eyes, 5.6% (1/18) required a second procedure within six months to achieve surgical success. A review of the literature suggests that 2% to 11% of patients who undergo primary En-DCR for primary acquired nasolacrimal duct obstruction require a revision.1-4

References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser

endonasal dacryocystorhinostomy. Ophthalmology 2003; 110: 78-84. 2Ben Simon GJ

et al. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal

duct obstruction in a tertiary referral center. Ophthalmology 2005; 112:1463-1468. 3Moore WM et al. Functional and anatomic results after two types of endoscopic

endonasal dacryocystorhinostomy. Ophthalmology 2002; 109: 1575-1582. 4Codere F

et al. Endonasal dacryocystorhinostomy: a modified technique with preservation of the

nasal and lacrimal mucosa. Ophthal Plast Reconstr Surg 2010; 26:161-164.

5.6%

2013 (N = 18)

International Benchmark

Page 35: Ophthalmology and Otolaryngology

exotropia (XT)esotropia (ET)

recession surgeryresection surgery

part of muscleresected

musclerecessed

muscleadvanced

after surgery

Recession and resection

procedures are most commonly

performed for horizontal

misalignment. Other surgeries

less frequently performed

include loop myopexies and

transpositions.

33

Pediatric and Adult Strabismus Surgery

Pediatric and Adult Strabismus Surgery: Outcomes Criteria

Strabismus surgery, the most commonly performed ophthalmic procedure in children,

is offered to adults as well. Surgery is performed for a variety of indications including

restoration of binocular vision, restitution of normal eye contact (reconstructive),

treatment of double vision, or reduction of anomalous head posture (torticollis).

Since the desired surgical outcome depends on the primary indication of surgery, we

developed a unique goal-directed methodology to assess surgical outcomes.1 This

approach provides the most clinically relevant appraisal of our outcomes. The model

excludes no patient based on diagnosis or procedure performed, and therefore facilitates

stratification based on the presence or absence of risk factors (ophthalmic or systemic)

that might impact results. The tables on the following pages summarize the criteria, and

the figures that follow illustrate our outcomes using this goal-directed methodology.

These reported pediatric and adult strabismus surgery outcomes include procedures

done at all surgical locations.

Reference: 1Ehrenberg M et al. Goal-determined metrics to assess outcomes of esotropia surgery. JAAPOS 2014;18:211-16.

Our goal-directed methodology

provides a clinically relevant

appraisal of strabismus surgery

outcomes. Reported results

were monitored two to six

months after strabismus

surgery was performed.

Page 36: Ophthalmology and Otolaryngology

34

Indications for strabismus

surgery included restoration

of binocular vision, restitution

of normal eye contact

(reconstructive), treatment of

double vision, or reduction

of anomalous head posture

(torticollis).

Pediatric and Adult Strabismus Surgery:Outcomes Criteria

1. Goal—Binocular Potential for Esotropia (ET)

Subjective Distance angle1 Near angle

Excellent ET≤10∆ or XT≤5∆ No XT, any ET

Good 10∆< ET≤15∆ or X(T)≤10∆ any ET

5∆<XT ≤10∆

Poor Recommend reoperation ET>15 or XT>10

(horizontal)

1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky

∆ = prism diopter

2. Goal—Binocular Potential for Exotropia (XT)

Sensory Distance angle1 Near angle

Excellent Near stereo-acuity <2 octaves XT<10∆ XT<10∆ worsened from pre-op and or ET<6∆ or ET<6∆

not diminished to nil2

Good Near stereo-acuity <2 octaves 10∆≤XT<15∆ 10≤XT<15∆

worsened from pre-op and or 6≤ET≤10∆ or 6≤ET≤10∆

not diminished to nil2

Poor Recommend reoperation XT>_15∆ XT>_15∆

(horizontal) or ET>>10∆ or ET>>10∆

1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky 2. Accept Worth-4-dot test (W4D) fusion if stereo-acuity data not available ∆ = prism diopter

3. Goal—Reconstructive (ET or XT)

Subjective Angle1,2

Excellent3 ET or XT≤10∆

Good 10∆<ET or XT≤15∆

Poor Recommend reoperation ET or XT>15∆

(horizontal)

1. Order of preference for angle used: Krimsky > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT)

2. Near angle (unless stated goal of distance angle)3. Ignore coexisting vertical deviation

Page 37: Ophthalmology and Otolaryngology

Although there were no

surgeries performed for

torticollis in calendar year

2013, there were four cases

in calendar year 2012.

35

4. Goal—Resolution of Diplopia (ET or XT)

Subjective

Excellent No diplopia in primary1

Good2,3 Diplopia controlled with prism

Poor Recommend reoperation for diplopia and/or diplopia

not comfortably controlled with prism correction

1. At distance and near but may have rare diplopia in primary, or diplopia away from primary2. Pre-existing vertical alignment controlled with prism does not affect result if no increase3. New vertical alignment requiring prism cannot exceed “good” outcome

5. Goal—Reduction of Torticollis (ET or XT)

Subjective1 Torticollis2

Excellent ≤8°

Good >8°≤12°

Poor Recommend reoperation for diplopia or torticollis >12°

1. Subjective category trumps the other categories 2. Distance (unless stated goal of near)

Pediatric and Adult Strabismus Surgery:Outcomes Criteria

Page 38: Ophthalmology and Otolaryngology

36

Of the 97 patients with

exotropia, 29 patients

underwent surgery to restore

binocular vision, 60 for

reconstructive purposes, and 8

for diplopia. Exotropia patients

are grouped according to the

primary goal for surgery.

Of the 97 patients with

exotropia who underwent

strabismus surgery in 2013,

50 patients had associated

risk factors.

Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by Goal

100

80

60

40

20

0

100

80

60

40

20

0

21.4

7.1

71.4

48.3

24.1

27.6

10.3

14.1

75.683.3

3.3

13.3

100.087.5

12.5 11.5

11.5

77.073.2

9.3

17.5

Perc

enta

gePe

rcen

tage

Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by Risk Factors

These graphs illustrate outcomes of exotropia surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear, during calendar years 2013 and 2012, when data collection began. Outcomes were graded as excellent, good, or poor, based on criteria determined by the primary goal of surgery. The results were then secondarily stratified based on the presence or absence of associated risk factors.

This figure presents outcomes for exotropia surgery in patients with or without associated risk factors. Risk factors included the following: bilateral vision limitation (e.g., albinism), conditions resulting in hyper- or hypotonia, craniosynostosis or craniofacial anomalies, 3rd nerve palsy, 4th nerve palsy, prior strabismus surgery, Duane syndrome, prior surgery for retinal detachment, Graves’ orbitopathy, antecedent orbital trauma with or without orbital fracture, congenital fibrosis of the extraocular muscles and simultaneous surgery for nystagmus or vertical strabismus.

%Excellent %Good %Poor

%Excellent %Good %Poor

BinocularPotential

2012(N = 28)

2013(N = 29)

2012No RiskFactors

(N = 25)

2012Risk

Factors(N = 3)

2012No RiskFactors(N = 5)

2012Risk

Factors(N = 9)

2013No RiskFactors

(N = 17)

2013Risk

Factors(N = 12)

2013No RiskFactors(N = 5)

2013Risk

Factors(N = 3)

2012No RiskFactors

(N = 40)

2012Risk

Factors(N = 38)

2012No RiskFactors

(N = 72)

2012Risk

Factors(N = 50)

2013No RiskFactors

(N = 25)

2013Risk

Factors(N = 35)

2013No RiskFactors

(N = 47)

2013Risk

Factors(N = 50)

2012(N = 78)

2013(N = 60)

2012(N = 14)

2013(N = 8)

2012(N = 122)

2013(N = 97)

Binocular Potential

Reconstructive

Reconstructive

Diplopia

Diplopia

Overall

Overall

72.0

8.0

20.033.3

66.7

47.1

29.4

23.533.3

5.015.8

4.0

20.09.7 14.0 10.6

24.0

16.7

10.0

18.4

4.0

2.933.3 9.7

14.012.8

6.0

50.0

85.0

65.8

92.0

77.1

100.0 100.0 100.0

66.7

80.672.0 76.6

70.0

Page 39: Ophthalmology and Otolaryngology

Of 146 patients with esotropia,

62 underwent surgery to

restore binocular vision, 63

for reconstructive goals, and

21 to resolve diplopia.

Of the 146 patients with

esotropia who underwent

strabismus surgery in 2013,

64 patients had associated

risk factors.

37

Pediatric and Adult Strabismus Surgery: Esotropia Outcomes Stratified by Goal

100

80

60

40

20

0

100

80

60

40

20

0

23.9

9.9

66.280.6

9.7

9.7 13.3

10.0

76.785.7

9.5

4.8

80.0

20.0

95.2

4.8

19.0

8.5

72.584.9

6.2

8.9

Perc

enta

gePe

rcen

tage

Pediatric and Adult Strabismus Surgery: Esotropia Outcomes Stratified by Risk Factors

These graphs illustrate outcomes of esotropia surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear, during calendar years 2013 and 2012, when data collection began. Outcomes were graded as excellent, good, or poor, based on criteria determined by the primary goal of surgery. The results were then secondarily stratified based on the presence or absence of associated risk factors.

This figure presents outcomes for esotropia surgery in patients with or without associated risk factors. Risk factors included the following: prior strabismus surgery, bilateral vision limitation (e.g., albinism), systemic conditions resulting in hyper- or hypotonia, craniosynostosis or craniofacial anomalies, Graves’ orbitopathy, antecedent orbital trauma with or without orbital fracture, prior surgery for retinal detachment, heavy eye syndrome, Brown syndrome, Duane syndrome, 6th nerve palsy, preoperative esotropia ≥ 50 prism diopters, congenital fibrosis of the extraocular muscles, and simultaneous surgery for nystagmus or vertical strabismus.

%Excellent %Good %Poor

%Excellent %Good %Poor

BinocularPotential

2012(N = 71)

2013(N = 62)

2012No RiskFactors

(N = 52)

2012Risk

Factors(N = 19)

2012No RiskFactors(N = 3)

2012Risk

Factors(N = 17)

2013No RiskFactors

(N = 49)

2013Risk

Factors(N = 13)

2013No RiskFactors(N = 9)

2013Risk

Factors(N = 12)

2012No RiskFactors

(N = 31)

2012Risk

Factors(N = 29)

2012No RiskFactors

(N = 86)

2012Risk

Factors(N = 67)

2013No RiskFactors

(N = 24)

2013Risk

Factors(N = 39)

2013No RiskFactors

(N = 82)

2013Risk

Factors(N = 64)

2012(N = 60)

2013(N = 63)

2012(N = 20)

2013(N = 21)

2012(N = 153)

2013(N = 146)

Binocular Potential

Reconstructive

Reconstructive

Diplopia

Diplopia

Overall

Overall

67.3

9.6

23.1

63.2

10.5

26.3

81.6

10.2

8.2

76.9

7.7

15.4

77.4

9.7

12.9

75.9

10.3

13.8

79.2

8.3

12.5

89.7

2.67.7

100.0

76.5

23.5

100.0

91.7

8.3

72.1

9.3

18.6

73.1

7.5

19.4

82.9

8.5

8.5

87.5

3.1

9.4

Page 40: Ophthalmology and Otolaryngology

38

Of the 350 procedures

performed for strabismus

correction, three (0.9%) were

complicated by postoperative

infections within 30 days of

the procedure. There were no

cases of associated vision loss.

Of the 367 strabismus

procedures performed, two

(0.54%) were complicated by

scleral perforation and

associated retinal hole. Both

were treated with laser

retinopexy, and neither case

developed retinal detachment.

Pediatric and Adult Strabismus Surgery: Scleral Perforation During Strabismus Surgery

Pediatric and Adult Strabismus Surgery: Infection Within 30 days After Surgery

10

8

6

4

2

0

10

8

6

4

2

0

Rat

e of

Scl

eral

Per

fora

tion

(%

)Po

stop

erat

ive

infe

ctio

n ra

te (

%)

Scleral perforation is a major complication of strabismus surgery, typically occurring during the reattachment of the eye muscles to the globe. An associated retinal hole can give rise to retinal detachment in some cases. This figure demonstrates the scleral perforation rate for strabismus surgery performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear during calendar year 2013.

Infection after intraocular or extraocular surgery may be complicated by postoperative infection. This figure demonstrates the postoperative infection rates for strabismus, cataract, and ptosis surgeries performed by ophthalmologists in the Pediatric Ophthalmology and Strabismus Service, a collaboration of the Children’s Hospital Ophthalmology Foundation (CHOF) and Mass. Eye and Ear during calendar year 2013.

0.54%

0.9%0.0% 0.0%

2013 (N = 367)

StrabismusSurgery

(N = 350)

PediatricCataractSurgery(N = 83)

PtosisSurgery(N = 40)

Page 41: Ophthalmology and Otolaryngology

39

For the past two years, the

Mass. Eye and Ear Neuro-

Ophthalmology Service has

maintained favorable rates of

follow-up for results of

outpatient imaging studies

compared to published

guidelines and international

benchmarks.

Of the 373 scans that were

ordered by a physician in the

Neuro-Ophthalmology Service

and also completed at Mass.

Eye and Ear in 2013, 354 scans

(94.9%) had documentation of

when the patient was notified

of the test results. Similar

results were reported for

calendar year 2012, during

which time 96.6%(348/360)

of scans had documentation

of follow-up with the patient.

A review of the literature

revealed that physicians

document their follow-up

with patients for 64.3% to

100% of scans ordered.4,5

Neuro-Ophthalmology: Imaging Study Results to Patients

During calendar year 2013, the Mass. Eye and Ear Neuro-Ophthalmology Service ordered

407 outpatient neuroimaging scans (e.g., MRI, CT scans, etc.). Thirty-four of these scans

were excluded from analysis because they were cancelled (21) or performed at outside

hospitals (13). This left a total of 373 scans for the current analysis. Follow-up rates reflect

the length of time from when the scan was performed to when the ordering physician

was able to successfully reach the patient (not necessarily the first call to the patient).

Of the 373 imaging studies included in the 2013 analysis, scan follow-up rates were

as follows: 102 scans (27.3%) were reviewed with the patient within one business day;

151 (40.5%) within two business days; 309 (82.8%) within seven calendar days; and

352 (94.4%) within 14 calendar days.

To the best of our knowledge, there are no ophthalmology studies that report the

percentage of patients who receive imaging results at specified time points. The Veterans

Health Administration (VHA) published guidelines in 2009 stating that all test results should

be given to patients within 14 calendar days after the test results are made available to the

physician. Similar guidelines have been published in the European community.1-3

References: 1Singh H, Vij M. Eight recommendations for policies for communicating abnormal test results. The Joint Commission

Journal on Quality and Patient Safety 2010; 36(5): 226-232. 2Sittig D, Singh H. Improving test result follow-up through electronic

health records requires more than just an alert. J Gen Intern Med 2012; 27(10): 1235–7. 3Rosenberg R et al. Timeliness of follow-

up after abnormal screening mammogram: variability of facilities. Radiology 2011; 261(2): 404-413. 4Callen J et al. Failure to

follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med 2011; 27(10): 1334-48. 5Casalino LP et al.

Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009; 169(12): 1123-1129.

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

2012 (N = 360)*

2013 (N = 373)

* Additional scans were identified for

calendar year 2012 that were not reported

in the previous publication. Inclusion of

these cases changed the rate of follow-up

within 24 hours from 150/348 (43.1%)

to 150/360 (41.7%); follow-up within 48

hours from 203/348 (58.3%) to 203/360

(56.4%); and within seven days from

327/348 (94%) to 327/360 (90.8%).

41.7%

27.3%

56.4%

40.5%

90.8%

82.8%

Within 24 business hours

Within 48 business hours

Within 7 calendar days

Page 42: Ophthalmology and Otolaryngology

40

On January 2, 2013, the

Mass. Eye and Ear Neuro-

Ophthalmology Service

launched a patient satisfaction

survey to prospectively

evaluate the patient experience

in the Neuro-Ophthalmology

Clinic. The voluntary survey

was completed by 295 patients

during the 2013 calendar year.

The results summarized here

reflect the responses of 165

new patients and 130

established patients, 55.9%

and 44.1%, respectively.

Prior to every appointment in

the Neuro-Ophthalmology

Clinic, patients are given

detailed information and

instructions to better prepare

them for the visit. These

instructions explain to the

patient that Neuro-

Ophthalmology visits are much

longer than most doctor visits,

that it is important to bring past

imaging studies (i.e., MRI or CT

scans), and that the dilated eye

exam will make their vision

blurry for a few hours after the

eye exam is completed. These

instructions are meant to better

inform the patients.

Neuro-Ophthalmology Service: Patient Satisfaction Survey

100

80

60

40

20

0

100

80

60

40

20

0

Excellent (N = 243)

Very Good (N = 47)

Good (N = 5)

Substandard (N = 0) N = 295

Excellent (N = 194)

Very Good (N = 63)

Good (N = 33)

Substandard (N = 5) N = 295

Excellent (N = 257)

Very Good (N = 33)

Good (N = 5)

Substandard (N = 0) N = 295

When asked to rate the overall quality of service, 290 patients (98.3%) responded that the quality of service in the Neuro-Ophthalmology Clinic was either “Excellent” or “Very Good.” The response options are indicated in the graph on the left.

When asked to rate the clarity of instructions that are given prior to their Neuro-Ophthalmology appointments, 87% of patients (257) responded that the clarity of the instructions was either “Excellent” or “Very Good.”

Two hundred ninety patients (98.3%) rated the friendliness and courteousness of the Neuro-Ophthalmology physicians as either “Excellent” or “Very Good.”

Qua

lity

of S

ervi

ce (

%)

Frie

ndlin

ess

of P

hysi

cian

s (%

)

82.4%

87.1%

15.9%

11.2%

1.7%

1.7%

0.0%

0.0%

100

80

60

40

20

0

Cla

rity

of

Inst

ruct

ions

(%

)

65.8%

21.4%11.2%

1.5%

Page 43: Ophthalmology and Otolaryngology

41

100

80

60

40

20

0

Based on their experience, 286 patients (97%) said they would be either “Extremely Likely” or “Very Likely” to recommend the Mass. Eye and Ear Neuro-Ophthalmology Service to others.

Like

ly t

o R

ecom

men

d (%

) 83.1%

13.9%2.7% 0.3%

Excellent (N = 238)

Very Good (N = 49)

Good (N = 8)

Substandard (N = 0) N = 295

100

80

60

40

20

0

Frie

ndlin

ess

of S

taff

(%

) 80.7%

16.6%

2.7% 0.0%

Two hundred eighty seven patients (97.3%) responded that the friendliness and courteousness of the administrative staff was “Excellent” or “Very Good.”

Extremely Likely (N = 245)

Very Likely (N = 41)

Likely (N = 8)

Not Likely (N = 1) N = 295

Page 44: Ophthalmology and Otolaryngology

42

Ocular Immunology and Uveitis Service: Percentage of Patients on Systemic Immunomodulatory Therapy

50

40

30

20

10

0

Pati

ents

tre

ated

wit

h sy

stem

ic m

edic

atio

ns (

%)

The Mass. Eye and Ear Ocular Immunology and Uveitis Service saw a total of 2,635 patients over 6,183 office visits during the 2013 calendar year. The calendar year 2013 data depicted here only includes the 1,724 patients seen at the main Boston campus. Of the 1,724 patients seen in 2013 by the Ocular Immunology and Uveitis Service, 469 patients (27.2%) were treated for ocular inflammation with some form of systemic medication, ranging from prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen, etc.) to oral corticosteroids (i.e., prednisone) to immunosuppressive agents (e.g., methotrexate, mycophenolate mofetil, etc.). The significant increase from 2012 to 2013 in the percentage of patients on systemic therapy for control of their ocular inflammatory disease could be partly explained by limiting the analysis to patients seen at the main hospital (a population of patients with more severe disease).

19.5%

27.2%

2012 (N = 2,525)*

2013 (N = 1,724)

* Data reported for the 2012

calendar year includes all patients

seen by the Uveitis Service at

any Mass. Eye and Ear location.

For calendar year 2013 data, the

graphed data depicts only patients

who were seen at the main

Boston hospital.

Treatment for uveitis (i.e.,

inflammation inside the eye) and

other ocular inflammatory

conditions requires a multi-

disciplinary approach that

involves internal medicine and

ophthalmology. At the Mass. Eye

and Ear Ocular Immunology and

Uveitis Service, patients are

treated with a range of

therapies, including topical eye

drops, prescription NSAIDs, and

systemic immunosuppressive

medications. In general, the use

of systemic immunomodulatory

therapy is an indicator of

increased disease severity.

(left) Photo of the right eye

of a patient with peripheral

ulcerative keratitis (PUK)

Photo courtesy of

George Papaliodis, M.D.

Page 45: Ophthalmology and Otolaryngology

43

Vision Rehabilitation Service: Vision-Specific Quality of Life Outcomes

Patients reported

improvement on all IVI

subscales with the greatest

improvement for reading.

3.0

2.0

1.0

0.0

IVI v

isio

n-sp

ecif

ic

qual

ity

of li

fe m

ean

scor

es When completing the Impact of Vision Impairment (IVI) questionnaire, patients are asked to rate if their eyesight interferes with everyday activities: (0) not at all, (1) a little, (2) a fair amount, or (3) a lot of the time. Lower scores represent better visual functioning.

Pre-Rehabilitation (N = 82)

Post-Rehabilitation (N = 82)

Total Reading Mobility Well-being

1.431.19

1.541.22

1.421.20

1.471.27

During 2013, 82 patients were enrolled in a prospective database and completed two questionnaires both prior to, and after, rehabilitation. Patient scores on both the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and the Impact of Vision Impairment (IVI) questionnaire indicate that many aspects of daily life and patients’ adjustment to vision loss are positively impacted by comprehensive vision rehabilitation. Mean scores of four NEI VFQ-25 subscales are displayed above with 100 being the best reported function.1 Changes post-rehabilitation are consistent with previously reported studies of vision rehabilitation outcomes.2,3

References: 1Mangione CM et al. Psychometric properties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ).

NEI-VFQ Field Test Investigators. Arch Ophthalmol. 1998;116(11):1496-504. 2Scott IU et al. Quality of life of low-vision patients

and the impact of low-vision services. Am J Ophthalmol 1999; 128:54-62. 3Kuyk T et al. Health-related quality of life following

blind rehabilitation. Qual Life Res 2008; 17:497-507.

100

90

80

70

60

50

40

30

20

10

0

NEI

VFQ

-25

visi

on-s

peci

fic

qual

ity

of li

fe m

ean

scor

es

Pre-Rehabilitation (N = 82)

Post-Rehabilitation (N = 82)

Previous Reported Outcome Studies2,3

General vision Near vision activities Mental health Dependency

45.0

51.4

41.4

49.0

42.3

50.355.6

61.8

The four NEI VFQ-25

subscales with greatest

improvement were general

vision, near vision, mental

health, and dependency.

55-57

45-66 45-54

57-66

30-38

39-46 46-59

34-43

Page 46: Ophthalmology and Otolaryngology

44

100

80

60

40

20

0

Ninety-five percent of patients reported that the explanation of their rehabilitation options was either “Excellent” or “Above Average.”

Excellent (N = 229)

Above Average (N = 21)

Average (N = 9)

Poor (N = 0)

No Response (N = 3) N = 262

Expl

anat

ion

of

reha

bilit

atio

n op

tion

s (%

) 87.4%

8.0% 3.4% 1.1%0.0%

100

80

60

40

20

0

Excellent (N = 250)

Above Average (N = 12)

Average (N = 0)

Poor (N = 0) N = 262

One hundred percent of patients rated their interactions with staff as “Excellent” or “Above Average.”

Inte

ract

ion

wit

h st

aff

(%)

95.4%

4.6%0.0% 0.0%

Based on their experience,

99% of patients said they

would recommend the

Mass. Eye and Ear Vision

Rehabilitation Service to

friends or family.

99% of patients treated by

the Vision Rehabilitation

Service rated the quality

of service as either “Excellent”

or “Above Average.”

100

80

60

40

20

0

The Mass. Eye and Ear Vision Rehabilitation Service offers multidisciplinary Comprehensive Vision Rehabilitation tailored to each patient’s unique goals. Interventions address difficulties with reading, activities of daily living, and patient safety. Interventions help patients to continue participation in activities despite vision loss, and visits also address the psychosocial adjustment to low vision. During 2013, 262 patients completed a six-question survey after their initial consultation.

Excellent (N = 236)

Above Average (N = 24)

Average (N = 2)

Poor (N = 0) N = 262

Qua

lity

of S

ervi

ce (

%)

90%

9.2%0.8% 0.0%

Vision Rehabilitation Service: Patient Satisfaction Survey

Page 47: Ophthalmology and Otolaryngology

Massachusetts Eye and Ear

O T O L A R Y N G O L O G Y D E P A R T M E N T

45

The Mass. Eye and Ear/Harvard Medical School Department of

Otolaryngology combines the expertise of highly specialized

otolaryngology physicians, audiologists, speech-language pathologists

and auxiliary healthcare professionals to provide clinical care for patients

with problems affecting the ear, nose, throat, head and neck areas. Our

clinical commitment is strengthened by our robust research presence,

as our physicians and scientists work together to advance the care we

provide to our patients.

Page 48: Ophthalmology and Otolaryngology

Mass. Eye and Ear/Harvard Medical School Department of Otolaryngology is firmly

committed to delivering excellence in clinical care, research and teaching. We provide

comprehensive medical and surgical care in a variety of subspecialties in the field of

otolaryngology, including:

• General Otolaryngology

• Pediatric Otolaryngology

• Audiology

• Otology and Neurotology

• Otoneurology

• Vestibular Disorders

• Head and Neck Oncology

• Laryngology

• Rhinology

• Facial Plastic and Reconstructive Surgery

• Facial Nerve Disorders

• Dermatology

• Laser Reconstructive Surgery

• Thyroid and Parathyroid Endocrine Surgery

We are also a center of research in these areas of expertise, with one of the largest and

most productive communities of otolaryngology researchers anywhere in the world. We

have a long history of medical breakthroughs, including the discovery of stem cells in

the adult inner ear and the ability to screen infants at birth for deafness. Our physicians

and scientists are committed to advancing the care we provide to our patients.

Department Highlights

• Primary teaching hospital and coordinating center for Harvard Medical School’s

Residency Program in Otolaryngology – Head and Neck Surgery.

• Home to a large community of otolaryngology researchers, including those

from the Eaton-Peabody Laboratories of Auditory Physiology, Jenks Vestibular

Physiology Laboratory, Jenks Vestibular Diagnostic Laboratory, Amelia Peabody

Otoimmunochemistry Laboratory, Otopathology Laboratory, Norman Knight Center

for Hyperbaric Medicine, National Temporal Bone, Hearing and Balance Pathology

Resource Registry, Facial Nerve Regeneration Laboratory, Carolyn and Peter Lynch

Center for Laser and Reconstructive Surgery and the Tillotson Cell Biology Unit.

46

Department of Otolaryngology Massachusetts Eye and Ear, Harvard Medical School

Page 49: Ophthalmology and Otolaryngology

For more information about

the Mass. Eye and Ear Quality

Program or the Department

of Otolaryngology, please

visit our website at

www.MassEyeAndEar.org.

Clinical Affiliations

• Massachusetts General Hospital (MGH)

- Mass. Eye and Ear physicians and audiologists provide comprehensive and

subspecialty care, including consultations and coordination of inpatient

consultations for urgent patient care concerns and newborn infant auditory

screening.

• Brigham and Women’s Hospital (BWH)

- Mass. Eye and Ear provides otology/neurotology subspecialty support to the

Otolaryngology Division of BWH.

• Mass. Eye and Ear Suburban Centers for Otolaryngology

- Mass. Eye and Ear physicians and audiologists provide comprehensive community-

based care throughout the greater Boston area, with locations in the Longwood

Medical Area of Boston, Braintree, Concord, Duxbury, East Bridgewater, Medford,

Milton, Newton-Wellesley, Quincy, Stoneham and Weymouth.

• Mass. Eye and Ear Balance and Vestibular Center at Braintree Rehabilitation Hospital

- Mass. Eye and Ear specialists provide comprehensive vestibular diagnostic

services, as well as otologic and neurologic assessment and care in a specialty

clinic housed at the Braintree Rehabilitation Hospital.

Academic Affiliations

• Massachusetts General Hospital

• Brigham and Women’s Hospital

• Beth Israel Deaconess Medical Center

• Boston Children’s Hospital

Otolaryngology Resources at Mass. Eye and Ear

• Full spectrum of primary and subspecialty otolaryngology care.

• Highly skilled clinical and research teams in each area.

• New England’s only dedicated otolaryngology emergency services with staff coverage

24 hours a day, 7 days a week and available for walk-ins.

• Audiology Department, providing a full range of diagnostic and treatment services

for patients with hearing loss, including newborn screening, audiometry, hearing aid

services and cochlear implant and auditory rehabilitation services for adults and children.

• Clinical Vestibular Testing, offering an array of the latest equipment and highly trained

staff to aid in diagnosis of vestibular and balance disorders in the Jenks Vestibular

Diagnostic Laboratory and at the Mass. Eye and Ear Balance and Vestibular Center

in Braintree.

47

Page 50: Ophthalmology and Otolaryngology

• Facial Nerve Center, offering full diagnostic, surgical and rehabilitative services for

patients with facial paralysis and movement disorders.

• Mohs Cutaneous Surgery Unit and Carolyn and Peter Lynch Center for Laser and

Reconstructive Surgery, providing care for a wide array of dermatologic disorders

and cancer.

• Head and Neck Oncology, providing the most up-to-date and effective evaluation

and treatment modalities for patients with head and neck cancer, including medical

oncology, microvascular surgery and collaboration with MGH radiation oncology

and proton beam facilities.

• Thyroid and Parathyroid Endocrine Surgery, offering diagnostic and surgical care

for patients with thyroid and parathyroid diseases of the head and neck, with world-

renowned expertise in nerve preservation and electrophysiological intraoperative

monitoring.

• Pediatric Airway, Voice and Swallowing Center, performing assessments and

treatment of a wide spectrum of these congenital, developmental and acquired

disorders in children.

• Voice Rehabilitation and Therapy, providing care for patients suffering from laryngeal

cancer, laryngeal motion disorders, hoarseness, papillomatosis and keratosis

and airway and voice disorders. Physicians work closely with speech-language

pathologists in the Mass. Eye and Ear Voice and Speech Laboratory, which provides

state-of-the-art audio and video diagnostic facilities, technicians and therapists.

• Sinus Center, providing clinical care to patients with all diseases of the nose

and sinuses.

• Sleep Center, providing polysomnography sleep diagnostic studies for assessment of

adults and children with sleep disturbances.

• Fully integrated access to all hospital support services and infrastructure, including

social work and discharge planning, the Howe Library, clinical and research IT, medical

unit, infectious disease unit, radiology unit, child life specialists, surgical pathology

unit, international program and language translation support, dietary support and

pharmacy services.

48

Page 51: Ophthalmology and Otolaryngology

Distribution of Otolaryngology Diagnoses

Data was collected and analyzed from 12,234 patients who received a diagnosis for an otolaryngologic complaint in the Mass. Eye and Ear Emergency Department between January 2011 and September 2013. The most frequent presenting complaints were related to the auditory or vestibular system (50.0%) (Figure 1). The five most common were impacted cerumen (10.8%), otitis externa (8.9%), otitis media (6.9%), epistaxis (6.0%) and hearing loss (5.6%) (Table 1).

Figure 1: Distribution of head and neck systems by frequency of presenting complaints

Table 1: Ten most common diagnoses among all patients

Diagnosis All Patients (N=12,234)

Impacted cerumen, No. (%) ......................................................................................................................1,322 (10.8)

Otitis externa, No. (%) ....................................................................................................................................... 1,085 (8.9)

Otitis media, No. (%) .................................................................................................................................................840 (6.9)

Epistaxis, No. (%)............................................................................................................................................................731 (6.0)

Hearing loss, No. (%) .................................................................................................................................................687 (5.6)

Sinusitis, No. (%) .............................................................................................................................................................547 (4.5)

Otalgia, No. (%) ..............................................................................................................................................................495 (4.1)

Dizziness or vertigo, No. (%) .............................................................................................................................362 (3.0)

Trauma, No. (%) ..............................................................................................................................................................354 (2.9)

Tonsillitis, No. (%) ..........................................................................................................................................................342 (2.8)

49

Mass. Eye and Ear provides

the region’s only dedicated

otolaryngology emergency

services with staff coverage 24

hours a day and 7 days a week.

The department provides care

for otolaryngology emergencies

on a walk-in basis.

Emergency Department: Otolaryngology

Other7%

Oral Cavity1%

Auditory/vestibular50%

Nasal/sinus12%

Pharyngealesophageal

11%

Post-operative5%

Skin/joints4%

Trauma3%

Neck2%

Neurological2%

Laryngeal2%

Facial/glands1%

Page 52: Ophthalmology and Otolaryngology

The Emergency Otolaryngology

Service at Mass. Eye and Ear

works in collaboration with

Mass General, which is

accessible to patients with

broader or associated medical

issues.

Distances Traveled for Specific Diagnoses

at the Massachusetts Eye and Ear Emergency Department

Patients originated from 42 states, although 93 percent were from Massachusetts. More than ninety percent of patients lived within a 50-mile radius of the Mass. Eye and Ear Emergency Department. For all patients, median travel distance was 9.6 miles. Established patients (9.4 miles) and new patients (9.6 miles) traveled similar distances (P=0.535). Visitors traveled similar distances for pediatric care (9.5 miles vs. 8.3 miles for an adult, P=0.811). Patients were willing to travel farther to seek specialized otolaryngologic care if it was a weekend (11.1 miles vs. 8.2 miles on a weekday, P<0.0001). Patients with hearing loss (11.1 miles) and trauma (10.3 miles) traveled the farthest, whereas those with impacted cerumen (7.1 miles) traveled the least (P<0.0001) (Figure 2).

Reference: Sethi R et al. Subspecialty emergency room as alternative model for otolaryngologic care: Implications for emergency

health care delivery. Am J Otolaryngol. 2014 Jul 10; pii: S0196-0709(14)00147-1.

50

MEEI

Less than 19

19-267

267-3712

3712 and above

Min: 6 (019)

Max: 3991 (017)

12

10

8

6

4

2

0ImpactedCerumen

Epistaxis OtitisExterna

PTA Sinusitis Trauma Hearing Loss

Med

ian

Trav

el D

ista

nces

(m

iles)

Page 53: Ophthalmology and 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

All patients undergoing laryngotracheal reconstruction (LTR) require postoperative tapering of sedation medication to prevent complications, especially sedation withdrawal symptoms. As part of ongoing quality initiatives, the Pediatric Otolaryngology Division implemented a standardized electronic sedation document and new training related to sedation medications for physicians, nurses and other health care providers. The initiative called for a real time, active decision-making process at the time of patient transfer from the pediatric intensive care unit to the floor setting. Over a two-year period, we examined the sedation wean in 29 consecutive pediatric patients who underwent LTR. With the new system-wide change, the mean length of sedation wean was reduced from 16.19 days to 8.92 days (p<0.05).1 Additionally, the number of patients requiring a narcotic prescription at the time of discharge decreased from 81.3 percent to 33.3 percent (p<0.05).1

References: 1Kozin ED et al. System-Wide Change of Sedation Wean Protocol Following Pediatric Laryngotracheal Reconstruction.

JAMA Otolaryngol Head Neck Surg. 2014 Oct 30. doi: 10.1001/jamaoto.2014.2694. 2Schall M et al. Guide for Field Testing:

Creating an Ideal Transition to the Clinical Office Practice. Institute for Healthcare Improvement 2009.

51

Using the Institute for

Healthcare Improvement (IHI)

methodology,2 the Pediatric

Airway, Voice and Swallowing

Center formed a multidisciplinary

team, including attending

pediatric otolaryngologists,

pediatric intensivists, hospitalists,

fellows, residents, nurses,

pharmacists and social workers to

address issues related to sedation

taper at Mass. Eye and Ear and

Mass General.

The team implemented a

system-wide process change that

significantly reduced the time

required for sedation wean and

decreased the number of

patients leaving the hospital

with a narcotic prescription.

Pediatric Otolaryngology

2011-2012 2012-2014

18

16

14

12

10

8

6

4

2

0

Wea

n D

urat

ion

(day

s)

Duration of Narcotics Wean after

Laryngotracheal Reconstruction

2011-2012 2012-2014

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge (

%)

Patients Undergoing Laryngotracheal

Reconstruction Requiring Narcotic

Prescription at Discharge

Page 54: Ophthalmology and Otolaryngology

Decannulation Rates in Pediatric Airway Surgery

A new technique for laryngotracheal reconstruction (LTR) to treat pediatric airway stenosis has been developed and implemented in the past three years at Mass. Eye and Ear. This technique, known as the hybrid or 1.5-stage LTR, combines aspects of both the single- and double-stage LTRs in order to improve outcomes while minimizing complications. It is particularly useful in the subset of patients who have poor lung function, multilevel airway obstruction, or developmental delay, as they would likely need a tracheostomy tube for additional reasons. However, this technique prevents the complication of airway inflammation and formation of granulation tissue from stent placement, as seen with the double-stage technique. From July 2011 to December 2013, thirteen patients underwent airway reconstruction using this technique. Of those patients, eight were decannulated within twelve months of surgery. Of those who were not decannulated, one required fundoplication for severe reflux, followed by revision LTR and is now preparing for decannulation; one has chronic lung disease preventing decannulation; one has severe tracheomalacia after tracheoesophageal fistula repair; one has severe stenosis after a motor vehicle accident; and one is currently preparing for decannulation. Including the two patients who are currently ready for removal of the tracheostomy tube, operation-specific and overall decannulation rates of 69.2% and 76.9%, respectively, are noted.

When compared to other published reports of patients undergoing single-stage LTRs (operation-specific and overall extubation rates = 80.2% and 93.4%, respectively), the decannulation rate in these patients is slightly lower due to other comorbidities. When compared to double-stage LTRs (operation-specific and overall decannulation rates = 50% and 80.2%, respectively), the results are similar. The hybrid laryngotracheal reconstruction is a useful technique in a subset of pediatric patients with airway stenosis. Early results suggest that the technique has comparable rates of decannulation without the complications seen in single- or double-stage LTR, which are the techniques performed in a similar patient population.

Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, September 2014, Orlando, FL.

References: 1Smith LP et al. Single- vs double-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 2010

Jan;136(1):60-5. 2Hartnick CJ et al. Surgery For Pediatric Subglottic Stenosis: Disease-Specific Outcomes. Ann Otol Rhinol

Laryngol. 2001;110:1109-13.

Physicians in the Pediatric

Airway, Voice and Swallowing

Center at Mass. Eye and Ear

developed this new technique—

hybrid laryngotracheal

reconstruction—by combining

aspects of both the single- and

double-stage laryngotracheal

reconstruction surgeries. Early

results show that the “hybrid”

method may lead to fewer

complications and better

outcomes.

52

Rate of decannulation

Decannulated/ready for decannulation

Narrow airway

Chronic lung disease

Page 55: Ophthalmology and Otolaryngology

The Audiology Department at Mass. Eye and Ear provides a full range of diagnostic

and treatment services for patients with hearing loss, including newborn screening,

audiometry, hearing aid services and cochlear implant and auditory rehabilitation

services for adults and children.

New Variable Predicts Hearing Aid Ownership

Logistic Regression Model: Word Recognition Performance v. Hearing Aid Ownership

Market surveys show that only 22% of those with hearing loss own hearing aids. This “rejection” is often ascribed to non-auditory factors like stigma, cosmetics and cost. However, our recent work shows that an auditory criterion — improved word recognition — predicts which patients will acquire hearing aids. We tabulated hearing aid ownership in 1,000 consecutive patients. We separated patients with hearing loss into two groups: one in which word recognition for soft speech (40 dB HL) could improve with gain supplied by a hearing aid, and another in which it did not. Both groups had audiometric thresholds within established fitting ranges. Like the national sample, exactly 22% of the hearing loss patients we sampled owned hearing aids. However, regardless of where patients received their hearing care, the group whose word recognition scores did not improve with level owned hearing aids at a rate of only 0.3%, while those whose word recognition could increase owned hearing aids at a rate of 50%. Results fit a logistic model where shift of the word recognition performance curve with level corresponded to the likelihood of ownership (see figure). These results provide a better market penetrance model and use audiologic data in a way that better predicts patient outcomes.

References: Kochkin S. MarkeTrak VIII: 25-year trends in the hearing health market. Hear Rev 2009; 16: 12–31.

Halpin C., Rauch S. Improvement in word recognition score with level is associated with hearing aid ownership among patients

with hearing loss. Audiol. Neurotol. 2012 17:139-147.

53

Hearing aid manufacturers

provide audiometric threshold

loss criteria (fitting ranges) as

guidelines for fitting hearing aids

to patients. These are easy to

apply, but provide only a glimpse

at the patient’s potential for

benefit.

We found that a different

hearing variable, improved word

recognition with level, is

consistent with ownership

outcomes. Using this variable

clinically results in a more

conservative fitting criterion, but

one that may better identify

those who can benefit from

hearing aid use.

Audiology

1.00

0.75

0.50

0.25

0.00

Level (dBHL) of 50% Predicted Performance [SII]

0 25 50 75 100 125

Prob

abili

ty o

f O

wne

rshi

p

normal word performance (in quiet)

Page 56: Ophthalmology and Otolaryngology

Physicians in the Otology and Neurotology Division focus on the structure and

function of the ear, as well as the nerves that connect the ear and the brain. They offer

treatment and rehabilitation strategies for a complete range of disorders of the ear.

Superior Semicircular Canal Dehiscence Syndrome (SSCD) Outcomes

In superior semicircular canal dehiscence syndrome (SSCD), the superior canal of the inner ear is missing a portion of its bony covering. This condition may be congenital or acquired and may result in a number of bothersome symptoms, including aural fullness and pressure in the affected ear, imbalance, autophony or tinnitus. If symptoms are debilitating enough, patients may undergo a surgical repair of the bone with plugging of the affected canal. Variation in the location of the bony dehiscence means that patients may require different surgical approaches.

Originally published in “Radiologic Classification of Superior Canal Dehiscence: Implications for Surgical Repair.” Otol Neurotol.

2014 Aug 13. Lookabaugh S et al.

54

Otology and Neurotology

Intact SSC

Bone overlying SSC

Ampulla

Arcuate eminence defect

Bone overlying SSC

Ampulla

Page 57: Ophthalmology and Otolaryngology

55

SSCD may result in a number

of bothersome symptoms,

including aural fullness (pressure

in the affected ear), dizziness or a

spinning sensation, autophony

(sensitivity to loud noise) or

tinnitus (pulsating ringing).

A review of surgical outcomes

revealed that auditory symptoms,

especially autophony and

pressure, are alleviated with

surgery for superior semicircular

canal dehiscence syndrome.

A New Classification System

A recent review of three hundred CT scans demonstrating SSCD at Mass. Eye and

Ear has produced a new classification system for SSCD.1 This work will help lead

neurotologic surgeons to better preoperative planning and, hopefully, to better

surgical outcomes.

Patient Symptoms Before and After Surgery for SSCD

An SSCD diagnosis is made based on clinical signs and symptoms, audiometric and balance testing as well as a high-resolution CT scan. Patients may have variable pre-operative complaints. For some individuals, the simple avoidance of triggers (straining, nose blowing) may be sufficient to alleviate their symptoms and may allow them to avoid surgery. Understanding which symptoms are most effectively relieved through surgery is critical for patient counseling. A review of SSCD surgical outcomes at Mass. Eye and Ear revealed that auditory symptoms are significantly reduced postoperatively.2 Patients with pre-existing migraine, disequilibrium, bilateral SSCD and large bony defects may experience a more prolonged recovery, though all of them noted satisfaction with their outcomes and resolution of their chief complaint.3 This information has helped surgeons better select patients for the procedure and also inform patients undergoing surgery of their expected outcomes.

References: 1Lookabaugh S et al. Radiologic Classification of Superior Canal Dehiscence Syndrome: Implications for Surgical Repair.

Otol Neurotol. 2014 Aug 13. [Epub ahead of print] 2Niesten MD et al. Clinical factors associated with prolonged recovery after

superior canal dehiscence surgery. Otol Neurotol. 2012 Jul; 33(5): 824-31. 3Jung DH et al. Dizziness is more prevalent than autophony

among patients who have undergone repair of superior canal dehiscence. Otol Neurotol. 2014 Aug. 13 (Epub before print)

30

25

20

15

10

15

10

5

0Autophony Aural

FullnessImbalance Pressure Tinnitus

Num

ber

of P

atie

nts

Preoperative Postoperative

0

25 25

3

20

24

3

6

19

0

Page 58: Ophthalmology and Otolaryngology

The Vestibular Division at Mass. Eye and Ear brings together otolaryngology and

otoneurology specialists to provide care for patients with vestibular and balance disorders.

Intratympanic Gentamicin Treatment for Ménière’s Disease Drop Attacks

Ménière’s disease is a degenerative inner ear condition causing progressive deafness and repeated attacks of whirling vertigo that can last for hours at a time. In approximately 90% of cases, the vertigo attacks can be controlled conservatively with a combination of diet and lifestyle changes plus medications. However, about 10% of cases require more aggressive treatment, most often by injection of the ototoxic drug gentamicin into the middle ear. Drop attacks are a rare and dangerous variant of Ménière’s disease in which patients are suddenly and violently thrown to the ground by their attacks without warning. Drop attacks have traditionally been treated by surgical labyrinthectomy to remove the balance organs. Of 3,450 patients with Ménière’s disease seen between 2000 and 2012, 320 had intratympanic gentamicin injections. Gentamicin was used to treat 24 cases of drop attacks. Initial control of drop attacks was achieved in 23/24 (95.8%). Only one drug injection was required in 20/24 (83.3%), while 2-4 injections were required in the other three ears. With a follow-up time of 12-120 months (mean = 43.5 months) after treatment, only two patients required subsequent labyrinthectomy for recurrent drop attacks. Gentamicin injections appear to be an excellent method of controlling Ménière’s drop attacks, avoiding the need for surgery in most cases.

Mass. Eye and Ear established

the Vestibular Division in the

Department of Otolaryngology in

July 2014, bringing together

otolaryngology and otoneurology

specialists who share clinical and

research interests in the

vestibular system. Together they

provide services, including state-

of-the-art vestibular diagnostic

testing, at Mass. Eye and Ear’s

main campus and at the Mass.

Eye and Ear Balance and

Vestibular Center at Braintree

Rehabilitation Hospital. In

addition to clinical care, they

engage in clinical and

translational research to improve

the lives of patients with

vestibular and balance disorders,

often in collaboration with

vestibular basic science

researchers. A formal Vestibular

Division offers structural

advantages and further positions

the Otolaryngology Department

at Mass. Eye and Ear as a leader

in this area of expertise.

Vestibular

Patients with Ménière’s disease

controlled medically

Patients with Ménière’s disease

controlled by IT gentamicin

Patients with Ménière’s disease drop

attacks controlled by IT gentamicin

Patients with Ménière’s disease drop

attacks who failed IT gentamicin and

needed labyrinthectomy

Total: 3,450

296

222

3,130

56

Mass. Eye and Ear established

the Vestibular Division in the

Department of Otolaryngology

in July 2014, bringing together

otolaryngology and

otoneurology specialists who

share clinical and research

interests in the vestibular

system. Together they provide

services, including state-of-the-

art vestibular diagnostic testing,

at Mass. Eye and Ear’s main

campus and at the Mass. Eye

and Ear Balance and Vestibular

Center at Braintree

Rehabilitation Hospital. In

addition to clinical care, they

engage in clinical and

translational research to

improve the lives of patients

with vestibular and balance

disorders, often in collaboration

with vestibular basic science

researchers. A formal Vestibular

Division offers structural

advantages and further

positions the Otolaryngology

Department at Mass. Eye

and Ear as a leader in this area

of expertise.

Page 59: Ophthalmology and Otolaryngology

57

The Head and Neck Oncology Division at Mass. Eye and Ear is firmly committed to

providing the highest quality care to patients with the most challenging and severe

malignancies of the head and neck region. For multiple reasons, including the exposure

to bacterially contaminated secretions such as saliva, surgical interventions of this region

are at a significant risk for infectious complications.

Free Flap Surgical Site Infection RatesIn conjunction with our Infectious Disease service, we reviewed 480 free tissue transfer reconstructive surgery cases (our most complex and time consuming surgical procedures for advanced cancers) over a 50-month period to assess our voluntary compliance with recommendations for prophylactic antibiotic use as utilized in other surgical fields as well as the overall infectious complication rate. Historically, infectious complication rates after advanced head and neck surgery are in the 20-40% range. This analysis revealed 99.8% compliance rate with prophylactic antibiotic administration and an infection rate of 13.3%, amongst the lowest reported for free tissue transfer surgery of the head and neck and in the largest series of patients. This data will allow us to institute and evaluate further initiatives designed to lower this relatively low infection rate further, limiting potential patient morbidity.

Author Flaps Cohort SSI Rate SSI Definition SSI Risk Factors

Jones 100 All defects 10% Not reported Not reported

Yang 129 Cancer 28.3% CDC Not reported

Bourget 137 All defects 28% Frank

purulence

Dehiscence, partial

flap failure

Mucke 156 Cancer 40.4% Purulent

discharge

Flap type, duration

of hospital stay,

need for flap

revision

Kamizono 182 Cancer 19% CDC Malnutrition, ASA,

XRT, bone flap

Dassonville 213 All defects 10% Not reported Not reported

Karakida 276 Cancer 40.6% CDC ASA, surgical

duration

Benatar 429 All defects 17% Not reported XRT

Mass. Eye

and Ear study

479 All defects 13.2% CDC None

ASA: American Society of Anesthesiologists CDC: Centers for Disease Control XRT: Radiation Therapy

Head and Neck Oncology

The study of free flap surgical

site infection rates at Mass. Eye

and Ear included the most flaps

(479) and is among the lowest

infection rates (13.2%) in a

comparison of similar series.

Page 60: Ophthalmology and Otolaryngology

Commonly Used Prophylactic Antibiotics in Free Tissue Transfer Reconstructive Surgery

Reference: Durand ML et al. The time course and microbiology of surgical site infections after head and neck free flap surgery.

Laryngoscope. 2014 Nov 25.

Shoulder Function Following Reconstruction with the Supraclavicular Artery Island Flap

The Division of Head and Neck Oncology continues to work toward improving reconstruction following surgery for head and neck cancers. We recently introduced the supraclavicular flap to our institution, and we’ve completed the only reported study to date to describe the objective and subjective outcomes at the donor site from this surgical procedure. We found that this flap harvest has no significant negative impact on overall shoulder function and quality of life. Subjective outcomes from two shoulder specific quality of life tools (Penn and Constant, as shown in the above graph) showed excellent results. Those patients with poorer outcomes also had concurrent neck dissection surgery that impacted shoulder function. Objective outcomes did reveal some limitation in range of motion, but this was equivalent to the non-operated shoulder and there was no loss of strength.

Reference: Herr MW et al. Shoulder function following reconstruction with the supraclavicular artery island flap. Laryngoscope. 2014;

2014 Nov;124(11):2478-83.

58

Continually tracking and

assessing infectious

complications occurring in

association with advanced head

and neck cancer surgery allows

for the institution and evaluation

of evolving protocols to further

decrease the frequency and

negative side effects of these

occurrences. Similarly,

appropriately directed antibiotic

use as part of such protocols can

curtail the evolution of

challenging antibiotic resistant

organisms.

In the right patient, the

supraclavicular artery island flap

provides an excellent

reconstructive option without

creating additional morbidity and

helping to optimize quality of

life. This finding is important

given the morbidity created by a

patient’s cancer.

Ampicillin/Subactam

Clindamycin

Cefazolin

Vanco +/-

Clinda/Levo

Other

None

Excellent

Good

Fair

Poor

2%2%

3%

9%

1% 0.2%

83%

10

8

6

4

2

0Penn Shoulder

ScoreConstant

Shoulder Score

Num

ber

of P

atie

nts

Page 61: Ophthalmology and Otolaryngology

59

The Laryngology Division at Mass. Eye and Ear is one of only a few laryngology centers

worldwide, comprised of physicians and other healthcare professionals dedicated to

treating disorders of the voice box and upper airway in adults.

Spasmodic Dysphonia

Spasmodic Dysphonia is a rare neurological voice disorder that can devastate personally,

socially and professionally. Affecting close to 50,000 people in the United States, it

is a type of focal dystonia, a neurological disease where the brain sends too many

signals causing unwanted movements in the larynx when the person tries to speak,

typically resulting in a strained/strangled voice quality. The larynx functions normally

during breathing, and technically there is nothing “wrong” with the larynx itself. It is a

problem in the brain that happens to affect voice production.

The standard treatment is an injection of Botox® into the muscles of the voice box

every few months in tiny amounts, in an outpatient-awake procedure that takes less

than 1 minute to decrease the force of contraction and improve voice production.

Although the treatment needs to be tailored to each patient’s case, members of the

Laryngology Division reviewed some of the spasmodic dysphonia cases treated at Mass.

Eye and Ear since 1994 in an attempt to summarize the disease course over 19 years.

We tracked close to 100 patients and found the age at first injection was 53 years

(range = 18-87). Seventy percent of these patients were women (age range 21-87) and

30 percent were men (18-87). As expected, the majority of patients (96 percent) had

the adductor-type (squeezing closed type) Spasmodic Dysphonia, while only 4 percent

had the abductor-type (opening type) Spasmodic Dysphonia. The adductor-type is

technically easier to treat, and the following data comes from this group.

We found stability in the disease over time with the mean dose of Botox® rising

from 2.35 units to 2.36 units. This patient cohort underwent an average of 14

injections with a mean time of 182 days between injections. They experienced 4 weeks

of breathiness after the injection followed by 17 weeks of good voice before needing

another injection.

Laryngology

• Botox® treatment for spasmodic

dysphonia is effective, offering

17 weeks of good voice after

4 weeks of breathy voice.

• Long-term Botox® dose

remains stable over years of

treatment for most patients.

• The average patient returned

for re-injection every 182 days.

• The average age at first

injection was 53 years.

• More women are affected

than men (70% women).

• 96 percent had adductor type

spasmodic dysphonia.

• Botox® injections are fast,

well tolerated and restore

good vocal function.

Page 62: Ophthalmology and Otolaryngology

Physicians in the Rhinology Division provide clinical care to patients with all diseases

of the nose and sinuses. They team up with specialists in allergy and immunology,

infectious disease, neurosurgery and radiology to provide a comprehensive approach

to managing nasal and sinus disorders.

Long-Term Outcomes in Sinus Surgery

Problems in Quality of Life

Patients with chronic sinusitis were assessed with validated surveys to better understand the impact of their disease on their quality of life. One instrument, the EuroQol 5-Dimension Assessment (or EQ-5D), was used for the first time in U.S. patients with sinus problems for this study. The EQ-5D provides important initial data on the burden of disease and helps us to quantify our patient outcomes. In this study, individuals with sinusitis were compared to the general U.S. population across quality of life domains. The graph demonstrates that patients with sinusitis report significantly more problems with pain and discomfort, anxiety and depression, as well as problems performing their daily activities than do patients without sinusitis.

Changes in Quality of Life after Sinus Surgery

Patients who underwent sinus surgery at Mass. Eye and Ear were assessed for changes in quality of life postoperatively. Scores in all three domains significantly improved, and this change was noticed up to 2 years after surgery. This study is the first of its kind to quantify changes in quality of life after sinus surgery using the EQ-5D. This information may be used to perform cost-effectiveness analyses and to help make sure that the benefits provided through surgical procedures are worthwhile to patients suffering from sinus diseases.

References: 1Remenschneider AK et al. The EQ-5D

- a new tool for studying clinical outcomes in

chronic rhinosinusitis. Laryngoscope. 2014 Nov 28. 2Remenschneider AK et al. Long-Term Outcomes in

Sinus Surgery: A New Tool for Measuring Health-Related

Quality of Life. Otolaryngol Head Neck Surg. 2014 Apr

4;151(1):164-170.

60

An important study is being

conducted at Mass. Eye and Ear

by Drs. Ralph Metson, Stacey

Gray, and Eric Holbrook; the

“Sinusitis Outcomes Study” is

the first of its kind to examine

quality of life in patients with

sinus disorders using the EQ-5D

survey, a tool that allows for

comparison with other common

diseases. The valuable

information they’ve collected

may be used to analyze cost-

effectiveness and to assess

quality of life benefits following

treatment for sinus disease.

Rhinology

Patients with Chronic Sinusitis — No Surgery

General Population

100

80

60

40

20

0Performing

Daily ActivitiesPain &

DiscomfortAnxiety & Depression

Perc

ent

of P

atie

nts

Rep

orti

ng P

robl

ems

Patients with Chronic Sinusitis Before Surgery

After Surgery

100

80

60

40

20

0Performing

Daily ActivitiesPain &

DiscomfortAnxiety & Depression

Perc

ent

of P

atie

nts

Rep

orti

ng P

robl

ems

Page 63: Ophthalmology and Otolaryngology

61

The Facial Plastic and Reconstructive Surgery Division is dedicated to the aesthetic and

functional enhancement of the head and neck.

Quality of Life Outcomes Following Functional Rhinoplasty in Patients with Nasal Obstruction

(NOSE: Nasal Obstruction Symptoms Evaluation)

Nasal obstruction is one of the most common complaints in otolaryngology practice. From September 2009 to January 2011, 60 patients who presented with nasal obstruction underwent functional rhinoplasty. Patients were asked to complete the Nasal Obstruction Symptom Evaluation (NOSE) and Sleep Outcomes Survey (SOS) questionnaires at 1 month, 3 months, 6 months and 12 months follow up. Both surveys are validated disease-specific QOL instruments used to quantify both patient symptomatology and interventional effect. Twenty-three percent of patients had internal nasal valve dysfunction (group 1), 26.7 percent had external nasal valve dysfunction (group 2) and 50 percent had combined dysfunction (group 3) before surgery. Following surgery, their NOSE and SOS scores indicate an overall significant improvement in quality of life.

Reference: Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope. 2012 Jul;122(7):1480-8. doi:

10.1002/lary.23345. Epub 2012 May 1.

Facial Plastic and Reconstructive Surgery

all subjects

internal nasal valve (Group 1)

External nasal valve (Group 2)

internal and external nasal valve

(Group 3)

Baseline, Mean 1-3 Months, Mean 6-12 Months, Mean

Score

66.42 (SD = 20.25) n = 60

21.85 (SD = 20.68) n = 54

22.33 (SD = 23.05) n = 45

61.79 (SD = 23.34) n = 14

13.46 (SD = 19.19) n = 13

4.09 (SD = 7.35) n = 11

59.60 (SD = 20.69) n = 16

22.69 (SD = 15.22) n = 13

18.85 (SD = 17.34) n = 13

72.17 (SD = 17.30) n = 30

25.36 (SD = 22.93) n = 28

34.05 (SD = 25.03) n = 21

0 10 20 30 40 50 60 70 80

On the NOSE scale, lower scores

indicate improved quality of life

Page 64: Ophthalmology and Otolaryngology

(SOS: Sleep Outcomes Survey)

Quality of Life Outcomes Following Correction of the Alar Base

in Patients with Flaccid Facial Paralysis

(NOSE: Nasal Obstruction Symptom Evaluation Score)

Nasal valve collapse caused by facial palsy is an often overlooked but disturbing sequela of flaccid facial paralysis. From March 2009 to December 2013, physicians in the Facial Nerve Center at Mass. Eye and Ear prospectively studied the effect of placement of a fascia lata sling placement for correction of external nasal valve compromise in 68 patients with flaccid facial paralysis, uti-lizing a validated disease specific quality of life outcome survey, the Nasal Obstruction Symptom Evaluation (NOSE) scale. Ratings were ascertained preoperatively and postoperatively. Sixty patients completed a NOSE survey prior to surgical intervention and 40 completed the survey after intervention. There was a statistically significant difference in NOSE scores after fascia lata sling (Wilcoxin signed-rank test, p<0.001). All patients had improvement in their nasal obstruction, which persisted uniformly in follow-up.

all subjects

internal nasal valve (Group 1)

External nasal valve (Group 2)

internal and external nasal valve

(Group 3)

Score

58.45 (SD = 18.24) n = 60

80.44 (SD = 17.28) n = 50

78.93 (SD = 18.46) n = 46

64.62 (SD = 22.57) n = 14

83.00 (SD = 18.77) n = 11

77.91 (SD = 22.00) n = 11

55.76 (SD = 17.69) n = 16

83.35 (SD = 10.46) n = 10

85.09 (SD = 16.26) n = 13

57.21 (SD = 16.43) n = 30

78.14 (SD = 18.71) n = 27

75.80 (SD = 18.13) n = 22

0 10 20 30 40 50 60 70 80 90

On the SOS scale, higher scores

indicate improved quality of life

On the NOSE scale, lower scores

indicate improved quality of life

62

Preoperative(mean +_ SD)

Postoperative(mean +_ SD)

Score (p-Value: < 0.001)

0 5 10 15 20 25 30 35 40

36.6 (SD = +_ 27.1)

16.76 (SD = +_ 17.37)

Baseline, Mean 1-3 Months, Mean 6-12 Months, Mean

Page 65: Ophthalmology and Otolaryngology

63

Before After

Reference: Prospective Evaluation of Quality of Life improvement after Correction of the Alar Base in the Flaccidly Paralyzed Face.

Lindsay RW et al. (JAMA Facial Plast Surg. 2015 Jan 2. [Epub ahead of print])

Page 66: Ophthalmology and Otolaryngology

The Thyroid and Parathyroid Endocrine Surgery Division at Mass. Eye and Ear strives

to effectively minimize commonly associated risks, including vocal cord paralysis (VCP),

in thyroid and parathyroid endocrine surgery by applying thorough preoperative

evaluation and utilizing nerve monitoring technology during surgery.

Surgical Outcomes in Professional Voice Users

A recent analysis of 27 articles that reviewed more than 25,000 patients undergoing

thyroidectomy found that the average postoperative VCP rate was 9.8% and ranged from

0 to 18.6%.1 VCP following thyroid surgery occurs due to injury to the recurrent laryngeal

nerve (RLN), while other voice-related complications of thyroid surgery arise from injury

to the external branch of the superior laryngeal nerve (EBSLN). Both the RLN and EBSLN

are closely related to the thyroid gland. Injury to the EBSLN can be challenging to identify

intraoperatively. This type of injury can cause easy voice fatigue, decreased pitch and

inability to project voice. Thus, thyroid surgery in professional voice users has much higher

stakes, as it can pose significant risk by affecting their career, livelihood and earning

capacity. VCP may also affect those engaged in religious vocal professions.

The Division recently reviewed surgical outcomes in professional singers/voice users,

the first such series in the world literature, which included many different genres of

performers, including 44% classical/operatic, 19% religious (including 1 Gospel, 1 Jewish

Cantor and 3 Choir), 25% pop/rock, 11% country & blues/folk, 4% Motown, 7% musical

theater performers, 7% music teachers and 7% others (1 voiceover artist and 1 television

meteorologist). Some patients indicated multiple genres of performance (figure 1).

We routinely employ RLN and EBSLN monitoring during surgery to aid in preventing

injuries. In our series of 27 singers and professional voice users, return to performance was

achieved in 100% of patients and the first postoperative performance occurred within

a mean time of 2.26 months from surgery. Vocal instrument mean scores showed no

statistically significant difference in preoperative vs. postoperative voice comparison (figure

2), indicative of successful vocal function preservation. Vocal instruments used were VHI

(voice handicap index), SVHI (singing voice handicap index) and EASE (evaluation of the

ability to sing easily). Most vocal professionals felt that vocal training to some extent was

helpful in their return to professional vocal performance.

Based on this unique series of professional voice users undergoing thyroid surgery,

the Division has identified key elements of operative approach, including RLN and

EBSLN nerve monitoring during surgery, minimum tissue handling and dissection and

pre- and postoperative laryngeal exam to achieve successful preservation of vocal

integrity in the professional voice user. These key elements will offer guidelines to

other thyroid surgeons, enabling them to achieve similar voice outcomes and counsel

professional singers anticipating thyroid surgery.

Reference: 1Jeannon JP et al. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. International

journal of clinical practice. 2009: 63:624-629.

64

Physicians in the Division of

Thyroid and Parathyroid

Endocrine Surgery at Mass. Eye

and Ear are some of the most

experienced in the world, having

performed more than 3,500 cases

of thyroid surgery with

intraoperative nerve monitoring.

Due to this high volume, they

have had extensive, specialized

experience operating on

professional voice users.

Thyroid and Parathyroid Endocrine Surgery

Page 67: Ophthalmology and Otolaryngology

65

Figure 1. Percentages of different genres of professional voice users in the study

(with some patients indicating multiple genres of performance)

Figure 2. Graph shows mean scores of different vocal instruments that were used to

evaluate voice before and after thyroid surgery. No difference was noted in pre- and

postoperative scores.

Comparison of mean preop and postop scores of vocal instruments

(No difference noted in before and after surgery scores)

These surgical outcomes show

that thyroid surgery is safe and

effective for professional voice

users. By following key elements

of operative approach, return to

professional performance after

thyroid surgery can be achieved

in 100% of singers and

professional voice users with the

mean time to return to

professional performance being

2.26 months.

A comparison of preoperative vs.

postoperative voice instrument

scores showed no difference in

quality of life after surgery.

Classical/Operatic

Pop/Rock

Religious

Country and Blues/Folk

Musical theater

Musicteacher

Other

Motown

0 5 10 15 20 25 30 35 40 45 50

44%

25%

19%

11%

7%

7%

7%

4%

Voc

al G

enre

14

12

10

8

6

4

2

0VHI SVHI EASE

Mea

n Sc

ore

Vocal instruments

Preoperative

Postoperative

Page 68: Ophthalmology and Otolaryngology

66

Page 69: Ophthalmology and Otolaryngology

Massachusetts Eye and Ear Infirmary

N U R S I N G D E P A R T M E N T

67

The Department of Nursing at Mass. Eye and Ear provides

quality care to a diverse population of adult and pediatric

patients in the specialties of Ophthalmology and

Otorhinolaryngology.

Patient/family centered care is the framework for nursing

practice. Specialty clinical education and the use of evidence-

based practice, combined with compassion and service

excellence, define the provision of nursing care. Nursing based

on a philosophy of holistic care supports the overall well-being

of the patient.

Shared governance and collaborative practice fosters an

environment that unites the care team with a single goal;

excellence. Through a collegial atmosphere, nurses and

physicians collaborate to ensure high quality outcomes.

During 2013, the Department of Nursing succeeded in

promoting professional practice, maintaining and exceeding

clinical benchmarks and recognizing the extraordinary

contributions made by the nursing staff.

Page 70: Ophthalmology and Otolaryngology

68

As a member of the National

Database of Nursing Quality

Indicator (NDNQI®), the

Department of Nursing has

chosen the RN survey with

Practice Environment Scale (PES)

survey tool for this annual

assessment of the Nursing

Practice Environment.

Using a 1-4 scale, our nurses

assessed the quality of the care

they delivered. Elements of this

assessment included the high

standards of nursing care

expected, competence of their

peers, and the presence of a

clearly defined philosophy of

nursing.

The Nursing Work Environment

The Department of Nursing recognizes that a professional work environment supports

professional practice and improves patient outcomes. The Department of Nursing conducts

an annual nursing work environment survey to assess the professional practice environment

of its nursing staff. This voluntary survey, completed by 97% of the registered nurse

workforce in 2013, a 6% increase from 2012, is designed to assess how the nurses feel

regarding the quality of care they deliver and their nurse-physician relations.

Nursing Practice Environment Scale (PES)

Annual Response Rate

The PES is endorsed by the National Quality Forums and includes a focus on:

• Nursing Foundation for Quality of Care

• Collegial Nurse-Physician Relations

Nursing Foundation for Quality of Care

100

80

60

40

20

02007 2008 2009 2010 2011 2012 2013

Perc

enta

ge

8689 91 91

8691

97

3.0

2.5

2.0

1.5

1.0

02007 2008 2009 2010 2011 2012 2013

2.82 2.86 2.91 2.89 2.912.99 2.98

Page 71: Ophthalmology and Otolaryngology

69

Mass. Eye and Ear’s mission and

vision seeks to promote

excellence in clinical care,

teaching and research. In support

of this, the organization provides

several avenues that foster

collegial nurse-physician

relations. The data reflects a

strong culture of collegiality

among nurses and physicians.

Nurses and physicians practice

Team-Based Simulations to

enhance crisis management of

medical emergencies. Mass. Eye

and Ear has a robust participation

in Schwartz rounds, which are

committed to providing the

opportunity for clinicians to

“re-fuel.” A majority of the

Schwartz rounds have panels

comprised of nurses and

physicians who share the stories

and challenges in providing

compassionate care. This also

contributes to the high level of

collegiality.

Collegial nurse-physician relations are promoted and fostered at Mass. Eye and Ear. The

clinical areas have a co-leadership structure comprised of nursing and physician leaders. This

structure is then adopted through other programs and activities. Through Interdisciplinary

Collaboration, evidence based – best practice is shared resulting in quality improvements.

Nurses along with physician colleagues actively participate in the annual meetings of

national organizations of eye and ear specialties such as the Society of Otorhinolaryngology

and Head and Neck Nurses and the American Society of Ophthalmic Registered Nurses.

Nursing and physician collaboration in research is evident at Mass. Eye and Ear, as noted by

the acceptance for publication of, “Heat and Moisture Exchange Devices for Patients

Undergoing Total Laryngectomy” (ORL Head Neck Nurs. 2014 Winter;32(1):20-3).

Collegial Nurse-Physician Relations

Nurse Quality Indicators (NDNQI®)

3.0

2.5

2.0

1.5

1.0

02007 2008 2009 2010 2011 2012 2013

2.85 2.75 2.84 2.802.95 2.98 2.97

2012, NO

0.26, 26%

2012, YES

0.74, 74%

2013, NO

0.22, 22%

2013, YES

0.78, 78%

2012, NO

0.07, 7%

2012, YES

0.93, 93%

2013, NO

0.06, 6%

2013, YES

0.94, 94%

Nurses felt they had enough time

with their patients

Nurses felt their discharged patients

were adequately prepared

Page 72: Ophthalmology and Otolaryngology

70

The PUP study team consists of

the Adult Unit’s Nursing

Leadership, a Nursing Staff

Champion and a Staff Specialist

from the Center for Quality &

Patient Safety. The team is

guided by the National Quality

Forum’s Nurse Sensitive Care

Outcome Measure®.

The PUP study, initially

conducted quarterly, was

increased to a monthly frequency

at the beginning of the 2013

fiscal year and continues on a

monthly basis.

Hand hygiene is the single most

important way to prevent the

transmission of infection.

Unannounced, randomized spot

checks are performed by

representatives from all

disciplines. Monitoring,

combined with education and

feedback, has resulted in high

levels of employee compliance.

Pressure Ulcer Prevalence Study (PUP)

Hospital acquired pressure ulcers have the potential to cause patient harm. Pain associated

with a pressure ulcer as well as extending the patient’s hospitalization can impact the quality

of their life. The aim of the Nursing Department is to prevent hospital acquired pressure

ulcers through identifying patients at risk to develop pressure ulcer and conducting routine

skin assessments. Monthly Pressure Ulcer Prevalence (PUP) rounds are conducted with a

team of nursing staff members to identify patients at risk and to ensure compliance with

prevention strategies. These prevention strategies are incorporated into the unit’s

purposeful rounding. Through the end of 2013, the Adult Unit has been Pressure Ulcer free

for 306 days.

Hand Hygiene

2.5

2.0

1.5

1.0

0.5

0.0Stage II

or greater2011

Stage III or greater

2011

Stage II or greater

2012

Stage II or greater

2012

Stage II or greater

2013

Stage II or greater

2013

Rat

e pe

r 1,

000

pati

ent

days

Perc

ent

1.75

0

1.56

0

.85

0

100

90

80

70

60

50

40

30

20

10

02011 2012 2013

The health care worker

performs hand hygiene

before each direct patient

contact with soap and water

or alcohol hand gel

The health care worker

performs hand hygiene

before each direct patient

contact with soap and water

or alcohol hand gel

90% Mass. Eye and Ear Benchmark

Page 73: Ophthalmology and Otolaryngology

71

Improving Outcomes through Pediatric Simulation Program: Pediatric Simulated Cardiopulmonary Resuscitation Event Response

The primary goals of the pediatric

simulation program are to

increase team building and

improve clinical skills, response

times and closed-loop

communication.

The Emergency Department

nurses implemented Hourly

Patient Rounding to keep

patients informed, manage

patient’s pain, discuss plan of

care and duration and continually

conduct patient assessments and

need for care.

Success has been found

through accountability and

consistency. The core culture of

rounding is an integrated aspect

of the Emergency Department’s

team approach to quality patient

care.

2011 — Year One

Enhanced knowledge base and skills of nurses, residents, fellows, and attendings

required to effectively manage pediatric codes within the pediatric unit. Empowered staff

through team training and role identification.

2012 — Year Two

Improved closed-loop communication and team leader identification; strengthening

interdisciplinary collaboration.

2013 — Year Three

Expanded simulations to include units outside the pediatric floor that provide pediatric care.

Increasing confidence in staff’s knowledge, skills, and communication.

Emergency Department Elopement

Hardwiring Patient Rounding in the Emergency Department resulted in major

improvements including reduced elopement rates (patients who leave before being seen).

num

ber

of p

atie

nts

50

40

30

20

10

0

Jan-

12

Mar

-12

May

-12

Jul-

12

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-

13

Sep-

13

Nov

-13

Page 74: Ophthalmology and Otolaryngology

72

Why I love my job

and Mass. Eye and Ear

Mass. Eye and Ear is my home

away from home. I love this

place. Twenty-three years ago I

sought employment for a night

RN position on the medical/

surgical unit to meet the needs

of my family. Although I

currently work in a very different

job position, I am honored to

work in such a great family

atmosphere. I have seen

enormous growth among staff

throughout the years.

Mass. Eye & Ear provides a

supportive environment that has

encouraged my professional

growth. I love the variety and

daily challenges in my current

operating room nurse position.

I am continually learning and

fascinated with the expertise of

our surgeons. I feel like I make

a difference in what I do and

that I am valued as an employee.

Thanks,

Your proud employee,

Nancy Kotzuba, R.N., M.S.N.

Participation in National Conferences

2013 SOHN 37th Annual Congress Vancouver, BC, CA -

Society of Otorhinolaryngology and Head and Neck Nurses

Hope for Breaking the Silence: Cochlear Implants vs. Auditory Brain Stem Implants

Andria Ledoux, R.N.

“I Am So Dizzy, My Head is Spinning” — Interventions of Meniere’s Disease

Amy Hanby, B.S.N., R.N.

Post-operative Bleeding after a Tonsillectomy or Tonsillectomy and Adenoidectomy as a

Common Complication

Shanna Pagliuca, R.N.

Development of a Transition of Care for Pediatric Patients with Critical Airway Conditions

across Institutions

Kevin Callans, B.S.N., R.N.

Building a Bridge… Finding a Voice

Ann Goulette, R.N., Jane Gallagher, R.N., & Kevin Callans, B.S.N., R.N.

2013 ASORN Annual Meeting - New Orleans, LA – American Society of

Ophthalmic Registered Nurses

Age-related Macular Degeneration “Up close and personal”

Jo Ann Graziano, M.M., R.N. & Mary Jo Graziano, B.S.N., R.N., B.B.A.

Hardwiring Patient Rounding in the Emergency Department at

Massachusetts Eye and Ear

Maureen Martinez, M.S., R.N.

Page 75: Ophthalmology and Otolaryngology

73

DAISY is an acronym for

Diseases Attacking the Immune

System. The Foundation was

formed in November, 1999, by

the family of J. Patrick Barnes

who died at age 33 of

complications of Idiopathic

Thrombocytopenic Purpura (ITP).

The DAISY Foundation

The founders of the DAISY Foundation wanted to say “thank you” to nurses everywhere

by establishing a recognition program to honor the super-human work nurses do for

patients and families every day. Nearly 1,700 healthcare facilities internationally, inpatient

and ambulatory care facilities from urban teaching hospitals to small rural community

facilities participate in the DAISY program. Over 40,000 nurses have been honored as

recipients of the award and nearly 400,000 nurses have been nominated.

In 2013, there were 46 nominations received for the DAISY award. The following

4 recipients were selected anonymously by the Professional Nurse Advisory Committee,

a council comprised of staff nurses.

2013 DAISY Award Recipients:

Cindy Close, R.N. —“We had a 7-year-old boy in the PACU from Shriner’s Burn

hospital. He was in the PACU for 2½ hours without his parents post-op. He really

enjoyed playing games on the iPad. […]Cindy Close, a PACU nurse was very taken by

this young man, his courage and his beautiful smile. She went online and ordered an

iPad for him to enjoy. She did this quietly and does not want any recognition. She truly

felt this act of kindness made her day.”

Pearl Icuspit, R.N. — “I witnessed her caring for a very ill patient in the IMCU. This

patient was anxious and having difficulty getting out secretions. Pearl came to her

side and immediately helped calm her with her soothing voice and gentle touch. Pearl

explained all of her actions to the patient as she was performing them. The patient was

very comfortable when she was done and Pearl was then able to teach the patient how

to take care of her secretions.”

Kristina Orlando, R.N. — “We met Kristina on our first visit to Mass. Eye and Ear. My

son needed an evaluation under sedation of his left eye due to a suspicious mass. A

week later, she made sure to be our nurse for what was the most traumatic experience

of my life. She remembered everything about our family. She requested a social worker

to visit us. She called down to the OR when they were late. She walked the halls with

us. I truly believe she is the reason I made it through that horrible day. When she got

off that day, she called the floor to check on us.”

Deb Trocchi, R.N. — “I went to EW and spoke to Deb asking what to do. Deb said

“Do not worry, let me take care of it.” She went outside and after speaking with the

parents she put the very agitated teenage girl with Down syndrome in a wheelchair

and brought her upstairs to the 12th Floor Retina service herself. This is not the first

time that I asked for Deb’s help at the EW. Kindness, professionalism... She calms down

the patients with her smooth voice and manners; she was definitely destined to be the

great nurse that she is and we are very lucky to have her here at Mass. Eye and Ear.”

Page 76: Ophthalmology and Otolaryngology

Ophthalmology Department Full-time and Affiliate Medical Staff and Practice Locations

Ophthalmology Central Referral and

Appointments Phone: 617-573-3202

Location: Mass. Eye and Ear Infirmary,

243 Charles Street, Boston, MA

Comprehensive Ophthalmology and

Cataract Consultation

617-573-3202

Service Director: Sherleen H. Chen, M.D., F.A.C.S.

Sheila Borboli-Gerogiannis, M.D., F.A.C.S.

Stacey C. Brauner, M.D.

Han-Ying Peggy Chang, M.D.

Matthew F. Gardiner, M.D.

Scott H. Greenstein, M.D., F.A.C.S.

Kristine Lo, M.D.

Christian E. Song, M.D.

Cornea and External Disease

617-573-3938

Service Director: Reza Dana, M.D., M.Sc.,

M.P.H., F.A.R.V.O.

Associate Service Director: James Chodosh,

M.D., M.P.H.

Joseph B. Ciolino, M.D.

Kathryn A. Colby, M.D., Ph.D.

Claes H. Dohlman, M.D., Ph.D.

Pedram Hamrah, M.D.

Deborah S. Jacobs, M.D.

Ula V. Jurkunas, M.D.

Deborah P. Langston, M.D., F.A.C.S.

Samir A. Melki, M.D., Ph.D.

Roberto Pineda, II, M.D.

Peter B. Veldman, M.D.

Emergency Ophthalmology and Eye Trauma

Emergency Department: 617-573-3431

Service Director: Matthew F. Gardiner, M.D.

Maggie B. Hymowitz, M.D.

Eye Trauma: 617-573-3022

Service Director: Alice C. Lorch, M.D. (AY15)

Yewlin Erin Chee, M.D. (AY14)

Glaucoma

617-573-3670

Service Director: Louis R. Pasquale, M.D.,

F.A.R.V.O.

Associate Service Director: Angela V. Turalba, M.D.

Teresa C. Chen, M.D.

Iryna A. Falkenstein, M.D.

Cynthia L. Grosskreutz, M.D., Ph.D.

Ambika S. Hoguet, M.D.

Pallavi Ojha, M.D.

Lucy Q. Shen, M.D.

Brian J. Song, M.D.

Janey L. Wiggs, M.D., Ph.D.

Neuro-Ophthalmology and Adult Strabismus

617-573-3412

Service Director: Joseph F. Rizzo, III, M.D.

Dean M. Cestari, M.D.

John W. Gittinger, M.D.

Simmons Lessell, M.D.

Ocular Tumors

617-573-3202

Han-Ying Peggy Chang, M.D.

Kathryn A. Colby, M.D., Ph.D.

Suzanne K. Freitag, M.D.

Evangelos S. Gragoudas, M.D.

Ivana K. Kim, M.D.

Daniel R. Lefebvre, M.D.

Michael K. Yoon, M.D.

Ophthalmic Pathology

617-573-3319

Service Director: Frederick A. Jakobiec, M.D., D.Sc.

Thaddeus P. Dryja, M.D.

Rebecca Stacy, M.D., Ph.D.

Ophthalmic Plastic Surgery

617-573-5550

Service Director: Suzanne K. Freitag, M.D.

Nahyoung Grace Lee, M.D.

Daniel R. Lefebvre, M.D.

Francis C. Sutula, M.D.

Michael K. Yoon, M.D.

Optometry/Contact Lens

617-573-3185

Service Director: Amy C. Watts, O.D.

Medical Director: James Chodosh, M.D., M.P.H.

Andrew D. Baker, O.D.

Mark M. Bernardo, O.D.

Shannon Bligdon, O.D.

Calliope Galatis, O.D.

Matt Goodman, O.D.

Kevin E. Houston, O.D.

Yan Jiang, O.D., Ph.D.

Charles D. Leahy, O.D., M.S.

Brittney J. Mazza, O.D.

Lotfi B. Merabet, O.D., Ph.D., M.P.H.

Amy Scally, O.D.

Pediatric Ophthalmology and Strabismus

(a collaboration on-site with Children’s Hospital)

617-355-6401

Ophthalmologist-in-Chief, Boston Children’s

Hospital: David G. Hunter, M.D., Ph.D.

Service Director, Mass Eye and Ear: Melanie

A. Kazlas, M.D.

Anna Maria Baglieri, O.D.

Kimberley Chan, O.D.

Linda R. Dagi, M.D.

Alexandra T. Elliot, M.D.

Anne B. Fulton, M.D.

Gena Heidary, M.D., Ph.D.

Suzanne C. Johnston, M.D.

Danielle M. Ledoux, M.D.

Iason Mantagos, M.D.

Kathryn B. Miller, O.D.

Robert A. Petersen, M.D., D.M.Sc.

Ankoor S. Shah, M.D., Ph.D., M.S.

Lois E. H. Smith, M.D., Ph.D.

Deborah K. VanderVeen, M.D.

Carolyn S. Wu, M.D.

Refractive Surgery

617-573-3234

Service Director: Roberto Pineda, II, M.D.

Ula V. Jurkunas, M.D.

Samir A. Melki, M.D., Ph.D.

74

Page 77: Ophthalmology and Otolaryngology

75

Retina Service

617-573-3288

Service Director: Evangelos S. Gragoudas, M.D.

Associate Service Director: Dean Eliott, M.D.

Jason I. Comander, M.D., Ph.D.

Deeba Husain, M.D.

Ivana K. Kim, M.D.

Leo A. Kim, M.D., Ph.D.

John I. Loewenstein, M.D.

Joan W. Miller, M.D., F.A.R.V.O.

Shizuo Mukai, M.D.

Lucia Sobrin, M.D., M.P.H.

Demetrios Vavvas, M.D., Ph.D.

David M. Wu, M.D., Ph.D.

Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.

Retinal Degenerations/

Electroretinography (ERG)

617-573-3621

Service Director: Eric A. Pierce, M.D., Ph.D.

Jason I. Comander, M.D., Ph.D.

John I. Loewenstein, M.D.

Xiang Werdich, M.D.

Uveitis and Immunology

617-573-3591

Service Director: George N. Papaliodis, M.D.

Reza Dana, M.D., M.Sc., M.P.H., F.A.R.V.O.

Ann-Marie Lobo, M.D.

Lucia Sobrin, M.D., M.P.H.

Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.

Vision Rehabilitation

617-573-4177

Service Director: Mary Lou Jackson, M.D.

Calliope Galatis, O.D.

Mass. Eye and Ear/Tele-Retinal Imaging

Program Director: Louis R. Pasquale, M.D.,

F.A.R.V.O.

Leo A. Kim, M.D., Ph.D.

Carolyn E. Kloek, M.D.

Brian J. Song, M.D.

Demetrios Vavvas, M.D., Ph.D.

David M. Wu, M.D., Ph.D.

Location: Mass. Eye and Ear/East Bridgewater,

400 North Bedford Street, East Bridgewater, MA,

Phone: 508-378-2058

Site Director: Angela V. Turalba, M.D.

(Glaucoma)

Daniel R. Lefebvre, M.D.

(Ophthalmic Plastic Surgery)

Louis R. Pasquale, M.D., F.A.R.V.O.

(Glaucoma)

Demetrios Vavvas, M.D., Ph.D. (Retina)

Location: Mass. Eye and Ear/Longwood,

800 Huntington Avenue, Boston, MA,

Phone: 617-936-6100

Site Director: Carolyn E. Kloek, M.D.

(Comprehensive/Cataract)

Mark M. Bernardo, O.D. (Optometry)

Sheila Borboli-Gerogiannis, M.D., F.A.C.S.

(Comprehensive/Cataract, Cornea/

Refractive)

Han-Ying Peggy Chang, M.D.

(Comprehensive, Cornea)

Iryna A. Falkenstein, M.D. (Glaucoma)

Yan Jiang, O.D., Ph.D. (Optometry)

Daniel R. Lefebvre, M.D.

(Ophthalmic Plastic Surgery)

Ann-Marie Lobo, M.D.

(Comprehensive/Cataract, Uveitis)

John I. Loewenstein, M.D. (Retina)

Zhonghui Katie Luo, M.D., Ph.D.

(Comprehensive/Cataract, Cornea/

Refractive)

Lucy Q. Shen, M.D. (Glaucoma)

Brian J. Song, M.D. (Glaucoma)

Peter B. Veldman, M.D. (Cornea)

David M. Wu, M.D., Ph.D. (Retina)

Location: Mass. Eye and Ear/Plainville,

30 Man Mar Drive, Suite 2, Plainville, MA,

Phone: 508-695-9550

Location: Mass. Eye and Ear/Providence,

One Randall Square, Suite 203, Providence,

RI, Phone: 401-453-4600

Southern New England Retina Associates

Site Director: Magdalena Krzystolik, M.D.

(Retina)

Paul B. Greenberg, M.D. (Retina)

Location: Mass. Eye and Ear/Stoneham,

One Montvale Avenue, Stoneham, MA,

Phone: 781-279-4418

Site Director: Matthew F. Gardiner, M.D.

(Comprehensive/Cataract)

Stacey C. Brauner, M.D.

(Comprehensive/Cataract)

Pedram Hamrah, M.D. (Cornea)

Ambika S. Hoguet, M.D. (Glaucoma)

Charles D. Leahy, O.D., M.S. (Optometry)

George N. Papaliodis, M.D.

(Comprehensive/Cataract, Uveitis)

Amy Scally, O.D. (Optometry)

Christian E. Song, M.D. (Comprehensive/

Cataract, Cornea/Refractive)

Angela V. Turalba, M.D. (Glaucoma)

Peter B. Veldman, M.D. (Cornea)

Michael K. Yoon, M.D. (Ophthalmic

Plastic Surgery)

Lucy H. Y. Young, M.D., Ph.D., F.A.C.S.

(Retina)

Location: Mass. Eye and Ear/Retina Consultants,

3 Woodland Road, Stoneham, MA,

Phone: 781-662-5520

Site Director: Deeba Husain, M.D. (Retina)

Jason I. Comander, M.D., Ph.D. (Retina,

Retinal Degenerations)

Leo A. Kim, M.D., Ph.D. (Retina)

Michael Pinnolis, M.D. (Retina)

Location: Mass. Eye and Ear/Waltham,

16 Trapelo Road, Suite 184, Waltham, MA,

Phone: 781-890-1023

Site Director: Jonathan Talamo, M.D.

(Cornea/Refractive)

Shannon Bligdon, O.D. (Optometry)

Kathryn Hatch, M.D. (Cornea/Refractive)

Nahyoung Grace Lee, M.D. (Ophthalmic

Plastic Surgery)

Christian E. Song, M.D. (Comprehensive/

Cataract, Cornea/Refractive)

Karen L. Zar, O.D. (Optometry)

Page 78: Ophthalmology and Otolaryngology

Emergency Otolaryngology

Emergency Department: 617-573-3431

Service Director: H. Gregory Ota, M.D.

General Otolaryngology

Gregory W. Randolph, M.D., F.A.C.S.*,

617-573-4115

Jean M. Bruch, D.M.D., M.D., 617-573-3793

John M. Dobrowski, M.D., 617-573-4104

Allan J. Goldstein, M.D., 617-573-3705

Facial Plastic and Reconstructive Surgery

Tessa A. Hadlock, M.D.*, 617-573-3641

Richard E. Gliklich, M.D., 617-573-4105

Linda N. Lee, M.D., 617-573-4105

Robin W. Lindsay, M.D., 617-573-3778

David A. Shaye, M.D., 617-573-4105

Skin Cancer and Mohs Surgery

Jessica L. Fewkes, M.D., 617-573-3789

Molly Yancovitz, M.D., 617-573-3789

Laser Reconstructive Surgery

Oon Tian Tan, M.D., Ph.D., 617-573-6493

Head and Neck Surgical Oncology

Derrick T. Lin, M.D., F.A.C.S.*, 617-573-3502

Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100

Kevin S. Emerick, M.D., 617-573-4084

Mark A. Varvares, M.D., 617-573-3192

Laryngology

Ramon A. Franco, Jr., M.D.*, 617-573-3958

Jean M. Bruch, D.M.D., M.D., 617-573-3793

Daniel G. Deschler, M.D., F.A.C.S., 617-573-4100

Christopher J. Hartnick, M.D., 617-573-4206

Phillip C. Song, M.D., 617-573-3557

Otology and Neurotology

Michael J. McKenna, M.D.*, 617-573-3672

D. Bradley Welling, M.D., Ph.D.**, 617-573-3632

Ronald K. de Venecia, M.D., Ph.D., 617-573-3715

David H. Jung, M.D., Ph.D., 617-573-3130

Daniel J. Lee, M.D., F.A.C.S., 617-573-3130

Alicia M. Quesnel, M.D., 617-573-3503

Steven D. Rauch, M.D., 617-573-3644

Felipe Santos, M.D., 617-573-3936

Konstantina M. Stankovic, M.D., Ph.D.,

617-573-3972

Vestibular

Steven D. Rauch, M.D.*, 617-573-3644

Richard F. Lewis, M.D., 617-573-3501

Adrian J. Priesol, M.D., 617-573-4148

Gregory T. Whitman, M.D., 617-573-6700

Pediatric Otolaryngology

Christopher J. Hartnick, M.D.*, 617-573-4206

Michael S. Cohen, M.D., 617-573-4250

Donald G. Keamy, Jr., M.D., 617-573-4208

Daniel J. Lee, M.D., F.A.C.S., 617-573-3130

Leila A. Mankarious, M.D., 617-573-4103

Rhinology

Eric H. Holbrook, M.D.*, 617-573-3209

Stacey T. Gray, M.D., 617-573-4188

Benjamin S. Bleier, M.D., 617-573-6966

Nicolas Y. Busaba, M.D., F.A.C.S., 617-573-3558

Thyroid and Parathyroid Endocrine Surgery

Gregory W. Randolph, M.D., F.A.C.S.*,

617-573-4115

Paul M. Konowitz, M.D., 617-573-4084

David J. Lesnik, M.D., 781-279-0971

Derrick T. Lin, M.D., F.A.C.S., 617-573-3502

Suburban Centers

Mass. Eye and Ear, Balance and Vestibular

Center at Braintree Rehabilitation Hospital

617-573-6700

Steven D. Rauch, M.D.*

Gregory T. Whitman, M.D.

Mass. Eye and Ear, Concord

978-369-8780

Michael H. Fattal, M.D.

Jennifer Setlur, M.D.

Michael A. Williams, M.D.

Mass. Eye and Ear, East Bridgewater

Main Line, 508-378-2059

Audiology Services, 508-350-2800

Mandana R. Namaranian, M.D.

Mass. Eye and Ear, Medford

781-874-1965

H. Gregory Ota, M.D.

David M. Bowling, M.D.

Mass. Eye and Ear, Newton-Wellesley

617-630-1699

Mark F. Rounds, M.D.*

Maynard C. Hansen, M.D.

Brian J. Park, M.D.

Kathryn A. Ryan, M.D.

Mass. Eye and Ear, Quincy

617-774-1717

Paul M. Konowitz, M.D., F.A.C.S.*

Peter N. Friedensohn, M.D.

Alex Grilli, M.D.

John B. Lazor, M.D., M.B.A., F.A.C.S.

Mandana R. Namiranian, M.D.

Edward J. Reardon, M.D.

Mass. Eye and Ear, Stoneham

781-279-0971

Michael B. Rho, M.D.*

David J. Lesnik, M.D.

Dukhee Rhee, M.D.

Mass. Eye and Ear, Weymouth-Duxbury

781-337-3424

Cathy D. Chong, M.D.

Amee K. Dharia, M.D.

Hani Z. Ibraham, M.D., F.A.C.S.

David S. Kam, D.M.D., M.D.

Monica S. Lee, M.D.

Otolaryngology Referral Line

617-573-3954

*denotes division leadership

**denotes chair of the department

76

Otolaryngology Department Medical Staff