our latest volume of Quality and Outcomes (Ophthalmology)

Q U A L I T Y A N D O U T C O M E S

Department of Ophthalmology

2015

Table of Contents

Letter from the President and CEO and the Chair of Ophthalmology ...........................1

About the Quality and Outcomes Program ..................................................................................................2

Ophthalmology Clinical Leadership in Quality: 2015 ........................................................................4

About Massachusetts Eye and Ear ...........................................................................................................................5

Department of Ophthalmology Overview .....................................................................................................6

Key Statistics .....................................................................................................................................................................................9

Emergency Department ...................................................................................................................................................10

Eye Trauma Service ...............................................................................................................................................................12

Comprehensive Ophthalmology and Cataract Consultation Service ............................14

Retina Service ..............................................................................................................................................................................16

Ocular Oncology Service ...............................................................................................................................................19

Glaucoma Consultation Service ..............................................................................................................................20

Cornea and Refractive Surgery Service ...........................................................................................................24

Ophthalmic Plastic Surgery Service .....................................................................................................................31

Pediatric Ophthalmology and Strabismus ...................................................................................................33

Neuro-Ophthalmology Service ................................................................................................................................39

Ocular Immunology and Uveitis Service .......................................................................................................42

Vision Rehabilitation Service .......................................................................................................................................43

Ophthalmology Department Full-time and

Affiliate Medical Staff and Practice Locations ................................................................................46

Contributors ..................................................................................................................................................................................48

Leading the way in making outcomes data publicly available…

Dear Colleagues in Health Care,

Physicians today want to practice evidence-based medicine, so that they can

diagnose and treat patients using the best available data. To accomplish this, they

usually refer to randomized clinical trials in which carefully matched groups of

patients are studied comparing an intervention, drug or surgery. Unfortunately, this

level of data exists for very few medical decisions and, even when it does, it may

not be helpful when considering options for an individual patient who doesn’t have

the exact same characteristics as those who were enrolled in the clinical trials.

Another way to examine the effectiveness of clinical practice involves studying

outcomes. How well do our patients see after cataract surgery? How successful are

our retina reattachment procedures? How often do our patients develop post-

operative infections? In other words, how well do our doctors, nurses and health

care professionals manage their patients?

Since 2010, Massachusetts Eye and Ear has led the medical community in the

development of ophthalmology outcome measures related to our areas of expertise,

and we have consistently reported on these measures in the Quality and Outcomes

book. These measures have evolved and grown considerably since our first issue.

The report provides us 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.

The Board of Quality Care Committee and the Steering Committee for Quality

would like to thank Chief Quality Officer for Ophthalmology, Dr. Teresa Chen, and

Associate Chief for Clinical Operations, Dr. Matthew Gardiner, for their leadership in

this project. We also wish to thank the clinicians, technicians, nurses and other staff at

Mass. Eye and Ear who work so hard to provide the highest quality care each day.

For more information about Mass. Eye and Ear’s Quality Program initiatives

and to view an electronic copy of this report, please visit our website at

www.MassEyeAndEar.org/Quality.

John FernandezPresident and CEO

Massachusetts Eye and Ear

Joan W. Miller, MDHenry Willard Williams Professor of Ophthalmology

Chief and Chair, Department of Ophthalmology


Massachusetts General Hospital

Harvard Medical School

1

About the Quality and Outcomes Program

2

Each year, Massachusetts Eye and Ear publishes the Quality and Outcomes book to

objectively evaluate our quality and outcomes for the public. Now in its sixth year of

reporting outcomes, the book serves as a testament to the premier care we provide

for our patients at Mass. Eye and Ear, and it is our hope that other institutions may be

inspired to consider publishing similar reports.

We have been a leader in the medical community for quality and outcomes in

a variety of ways. In ophthalmology—for instance—the international benchmark

in cataract surgery for achieving within 1 diopter of target refraction is between 71

and 94 percent.1 Even though we have always exceeded international benchmarks,

our latest data show that we now exceed the upper range, with 96 percent of our

patients achieving target refraction criteria. Our outcomes measure was submitted

to Medicare and is now a nationwide outcomes measure. Mass. Eye and Ear also

has some of the lowest reported rates of endophthalmitis after intravitreal injections,

which is one of the most common outpatient procedures in ophthalmology.2

Behind the Quality and Outcomes book is the Mass. Eye and Ear Quality

Program, an institutional initiative directed by the Board of Quality Care Committee

and the Steering Committee for Quality, which meets weekly to review issues in four

core areas: outcomes, provider excellence, clinical incidents response and process

improvement. These meetings provide a forum for close interaction between quality

leaders in Ophthalmology, Otolaryngology, Anesthesia, Nursing, Legal, Information

Services and others, fostering a team approach to achieve best practices and enhance

communication between functional areas of the hospital.

When problems do arise, clinical incidences are tracked electronically and

subsequently reviewed by the Steering Committee for Quality, which works together

to identify trends and implement a correction plan. We work with other hospital

committees, including the OR committee, infection control, medical records, patient

family advisory council and others, when we need their expertise and advice on

certain issues.

For example, in a past Steering Committee for Quality meeting, we had

addressed a cataract surgery case with a wrong intraocular lens (IOL), a serious

reportable event. During the post-event review process, we found that poor

handwriting on the order form was the root cause of this wrong IOL. We corrected

the problem by mandating that all IOL orders be typed. We published our “lessons

learned” in the journal Ophthalmology in 2012, addressing the issues associated

with wrong IOLs, which is one of the most common preventable medical errors

in ophthalmology.3

In 2015, Dr. Miller and I shared our experience in creating and implementing

new policies in a paper published in JAMA Ophthalmology, “Sentinel Events,

Serious Reportable Events and Root Cause Analysis.”4 The paper describes our

multidisciplinary team approach for identifying the primary or root cause of sentinel

events, with the ultimate goal of improving quality and outcomes in ophthalmology.

Our article is one of the first to demonstrate how leadership can create and reinforce

new policies that improve ophthalmology outcomes.

Today, the Mass. Eye and Ear Quality Program remains committed to publishing

a robust and transparent assessment of quality care report each year. We hope you

find the publication interesting and useful, and we welcome your comments and

feedback. It is our hope that we can continue to set new standards for outcomes

achieved in our field.

Teresa C. Chen, M.D.Chief Quality Officer for Ophthalmology

Department of Ophthalmology



1Simon SS, Chee Y, Haddadin RI, Veldman PB, Borboli-Gerogiannis S, Brauner SC, Chang KK, Chen, SH, Gardiner MF,

Greenstein SH, Kloek CE, Chen TC. Achieving Target Refraction After Cataract Surgery. Ophthalmology. 2014;121(2):440-4.2Englander M, Chen TC, Paschalis EI, Miller JW, Kim I. Intravitreal Injections at the Massachusetts Eye and Ear

Infirmary: Analysis of Treatment Indications and Postinjection Endophthalmitis Rates. British Journal of Ophthalmology.

2013;97(4):460-5. 3Schein OD, Banta JT, Chen TC, Pritzker S, Schachat AP. Lessons Learned: Wrong Intraocular Lens.

Ophthalmology. 2012 Oct;119(10):2059-64. 4Chen TC, Schein OD, Miller JW. Sentinel Events, Serious Reportable Events

and Root Cause Analysis. JAMA Ophthalmology. 2015 Jun;133(6):631-2.

3

Ophthalmology Clinical Leadership in Quality: 2015

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

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

Matthew Gardiner, M.D.Assistant Professor of Ophthalmology, Harvard Medical SchoolAssociate Chief for Clinical Operations, Massachusetts Eye and Ear

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

Debra Rogers, M.S.Vice President for OphthalmologyMassachusetts Eye and Ear

Deborah Cronin-Waelde, RN, MSN, NEA-BCDirector of Operations, OphthalmologyMassachusetts Eye and Ear

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

4

Clinical Locations

Boston — Main Campus

Boston — Longwood

Boston — Joslin

Braintree

Concord

Duxbury

East Bridgewater

Medford

Milton

Newton

Plainville

Providence

Quincy

Stoneham

Waltham

Weymouth

For more information, visit

MassEyeAndEar.org/Locations.

About Massachusetts Eye and Ear

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

and research hospital dedicated to caring for disorders of the eyes, ears, nose, throat,

head and neck. Our dedicated staff provides primary and 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 Otolaryngology, we are deeply committed

to providing a superb education to the next generation of visionary health care

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 Partners eCare, a highly

integrated health and administrative information system that primarily uses

the software vendor Epic. Partners eCare is utilized by the majority of Harvard

Medical School’s network of hospitals and affiliates, facilitating 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 access our specialists, affording seamless and rapid access to some of

the best ophthalmology and otolaryngology resources available.

2014 Hospital Statistics

(Jan 1 – Dec 31, 2014)

Patient Volume

Outpatient services .............................................................................................411,917

Ambulatory surgery services and laser .............................................27,715

Inpatient surgical services ........................................................................................998

Emergency Department services .............................................................19,898

Discharges ............................................................................................................................1,263

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

Overall Operating Revenue ..................................................... $379,146,039

Stoneham

5

Academic Affiliations


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

VA Maine Healthcare System

Cambridge Health Alliance

Aravind Eye Hospital, India

Eye and ENT Hospital of Fudan University, Shanghai, China

At 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.

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:

Ocular Genomics Institute

Ocular Regenerative Medicine Institute

Infectious Disease Institute

Age-related Macular Degeneration Center of Excellence

Cornea Center of Excellence

Diabetic Eye Disease Center of Excellence

Glaucoma Center of Excellence

Mobility Enhancement & Vision Rehabilitation Center of Excellence

Ocular Oncology Center of Excellence

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.

6

Massachusetts Eye and Ear Ophthalmology Department

For more information about

the Mass. Eye and Ear Quality

Program or the Department

of Ophthalmology, please

visit our website at

www.MassEyeAndEar.org.

• 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 Boston to prevent, diagnose and

treat patients at risk for diabetic eye disease.

Brigham and Women’s Hospital (BWH)

• Mass. Eye and Ear ophthalmologists provide subspecialty care in glaucoma,

cornea, and pediatric retina surgery at Boston Children’s Hospital.

• BWH patients also receive a full range of ophthalmic care including Same

Day Service urgent consultation and evaluations at Mass. Eye and Ear,

Longwood, 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,

cornea, and pediatric retina surgery 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 Inherited Retinal Disorders 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.

7

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

and nurse practitioners.

• The Mass. Eye and Ear 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 offers patients assistance with appointments,

transportation, accommodations and language translation.

• Mass. Eye and Ear’s Retina Service houses a dedicated ophthalmic ultrasound

imaging suite as part of the Minda de Gunzburg Retinal Imaging Center.

8

cornea

lens

pupil

iris

sclera retina

macula

optic nerve

vitreous

Data reported for 2010,

2011, 2012, 2013 and 2014

represent calendar years.

The 2009 data represent

12-month results as noted.

Eye Anatomy

Key Statistics: Mass. Eye and Ear OphthalmologyJanuary 1 – December 31, 2014

• The Ocular Melanoma Center, a premier referral center for the diagnosis and

treatment of eye tumors, draws patients from around the world

• The Altschuler Surgical Training Laboratory (estimated completion date:

fall 2016) will serve as a cornerstone of the surgical training program at Mass.

Eye and Ear/Harvard Ophthalmology, and will house state-of-the-art surgical

equipment, training machines for vitreoretinal and cataract surgery, a proctor

station with a plasma screen, and other technological improvements.

9

Subspecialty Patient Visits

Outpatient Ophthalmology Visits

Comprehensive Ophthalmology ............................................................................................................................37,181

Trauma .........................................................................................................................................................................................................420

Cornea ................................................................................................................................................................................................18,982

Optometry ......................................................................................................................................................................................12,005

Ophthalmic Plastic, Reconstructive Surgery ................................................................................................. 7,932

Glaucoma.........................................................................................................................................................................................18,834

Immunology and Uveitis.................................................................................................................................................... 6,428

Inherited Retinal Disorders Service ...............................................................................................................................694

Neuro-Ophthalmology ........................................................................................................................................................ 5,061

Retina ...................................................................................................................................................................................................36,176

Vision Rehabilitation Service ................................................................................................................................................942

Total Outpatient Ophthalmology Visits ..................................................................................................... 144,655

Emergency Room Visits

Total number of Ophthalmology visits ...........................................................................................................12,584

Surgical Procedures

Total number of Ophthalmology surgeries ................................................................................................11,387

Total Ophthalmology laser procedures .............................................................................................................. 3,025

Refractive........................................................................................................................................................................................626

Total intravitreal injections ............................................................................................................................................... 9,458

10

Emergency Department: Ophthalmology Emergency Visits

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 = 13,757)

2013 (N = 13,709)

2014 (N = 14,270)

Month

For the past six years, the

average ophthalmology visit

time in the Mass. Eye and Ear

Emergency Department was

better than the average national

and state visit times.

Emergency Department: Ophthalmology Visit Times

5

4

3

2

1

0

2.32.1

2.3

3.0 3.1

Massachusetts Average 4.06 Hours

Hou

rs

The average ophthalmology visit time in the Mass. Eye and Ear Emergency Department for 2014 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 fin-ished the visit with the ophthalmologist. According to the 2010 Press Ganey Emergency Department Pulse Report, patients across the United States spent an average of four hours and seven minutes (4.12 hours) per emergency room (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 = 13,757)

2013 (N = 13,709) 2014 (N = 14,270)

*October 2008 – September 2009

2.7

This bar graph shows the

number of ophthalmology

patients seen monthly by the

Mass. Eye and Ear Emergency

Department during the past

six 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, 1,146 in 2012,

1,142 in 2013 and 1,189 in

2014. Patient volume generally

increases in the summer.

The Mass. Eye and Ear

Emergency Department

has a lower LWBS rate

when compared to national

benchmarks.

11

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

10

9

8

7

6

5

4

3

2

1

0

“Left without being seen” (LWBS) refers to patients who present to an emergency department but leave before being seen by a physician. The Mass. Eye and Ear Emergency Department reported a LWBS rate of 1.0% (146 patients for all 14,270 ophthalmic emergency visits) in 2014; similar results were reported for calendar years 2012 and 2013. 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, Ho GK, Hill PM, McCarthy ML, Pronovost PJ.

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, Asch SM,

Weiss RE, Zingmond D, Liang LJ, et al. Hospital determinants of emergency

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

24-32.e3. 3Handel DA, Fu R, Daya M, York J, Larson E, John McConnell

K. The use of scripting at triage and its impact on elopements. Acad Emerg

Med 2010; 17(5): 495-500.

Vitreous Degeneration (N = 876)

Superficial Injury of Cornea (N = 812)

Tear Film Insufficiency, Unspecified (N = 508)

Unspecified Diseases of the Conjunctiva Due to Viruses (N = 501)

Pain In or Around the Eye (N = 419)

Conjunctival Hemorrhage (N = 378)

Corneal Foreign Body (N = 368)

Corneal Ulcer, Unspecified (N = 306)

Chalazion (N = 258)

Blepharitis, Unspecified (N = 236)

Hordeolum Externum (N = 224)

Unspecified Retinal Detachment (N = 222)

Other Vitreous Oapacities (N = 189)

Foreign Body in Unspecified Site on External Eye (N = 188)

Contusion of Eyeball (N = 185)

Other Chronic Allergic Conjunctivitis (N = 178)

Unspecified Iridocyclitis (N = 176)

Other Unspecified Visual Disturbances (N = 172)

Vitreous Hemorrhage (N = 171)

Redness or Discharge of Eye (N = 128)

1.7% to 4.4% 1-3

Perc

enta

ge

1.3% 1.2% 1.0%

2012 (N = 13,757)

2013 (N = 13,709)

2014 (N = 14,270)

National Benchmark

During calendar year 2014,

there were 14,270 ophthalmic

emergency visits to the

Mass. Eye and Ear Emergency

Department. Of these, 12,610

visits were initial encounters

and are included in this

distribution analysis. The

following graph depicts the top

20 diagnoses for all ophthalmic

emergency visits during 2014.

Emergency Department: Distribution of Ophthalmology Diagnoses

0 200 400 600 800 1,000

Number of diagnoses

12

In a retrospective review of

124 pediatric open-globe

injuries managed by the Eye

Trauma Service and/or Retina

Service between February

1999 and April 2009, analysis

showed a median visual acuity

at presentation of “hand

motion” (N = 123), and a final

best corrected median visual

acuity of 20/40 (N = 124) at ten

months median follow-up1

Eye Trauma Surgery: Postoperative Median Vision

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)

2014(N = 74)

20/70

20/100 20/100

Light Perception

CountFingers

Hand Motion

Hand Motion

Hand Motion

20/60

20/40

During the 2014 calendar year, 119 eyes of 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 analysis, 74 eyes of 73 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 2014 calendar year, the median preoperative vision was “hand motion” and the median postoperative vision at the closest follow-up visit after five months was 20/100. 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 [abstract]. J AAPOS 2011; 15(1): e29.

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 Motion

Light Perception

No Light Perception

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

During calendar year 2014, 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, 118 (100.0%) were taken to the operating room within 24 hours of arrival at Mass. Eye and Ear. The mean time from presentation at the Emergency Department to arrival in the operating room was 430.8 minutes, or 7.2 hours (range: 0 minutes to 22 hours). Of the 118 patients, 93 (78.8%) were taken to the operating room in under 12 hours. Multiple studies suggest the benefit of repairing open-globe injuries within 12 to 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 at the main campus and at affiliate hospitals.

100

80

60

40

20

0

2012 2013 2014

Perc

enta

ge

< 12 hours < 24 hours

Time to Operating Room

100.0

69.776.3 78.8

99.299.2

During calendar year 2014, 118 patients had open-globe repair by the Eye Trauma Service for all surgical locations. Of these 118 patients, two (1.7%) developed endophthalmitis. Low infection rates were also reported for calendar years 2009, 2010, 2011, 2012, and 2013, as shown in the graph. The first case of endophthalmitis was a 31-year-old male with delayed presentation to Mass. Eye and Ear (> 24 hours) and with Zone I injury. He had surgical repair of a corneal laceration, but lensectomy was deferred at the time. On post-operative day 4, he had increased inflammation, which was presumed to be from lens capsular violation. He underwent phacoemulsification with intraocular lens, but on the third day after the cataract surgery, he presented with increased inflammation, pain, and decreased vision. Vitreous culture grew coagulase-negative staphylococci. Although his vision on presentation had been 20/30, his vision at 15 months was 20/500 after three retinal detachment repairs. The other case of endophthalmitis was a 34-year-old male with a Zone II injury from a metal shim. One day after repair of a 1mm scleral wound that was 4 mm posterior to the limbus, the patient had 20/25 vision but also had extensive anterior chamber and fibrin reaction, which was concerning for endophthalmitis. He was treated with intravitreal antibiotics; however, the vitreous culture was negative. His postoperative course was complicated by a macula-off retinal detachment. His final best corrected vision was 20/50 with an aphakic contact lens.

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 rate of endophthalmitis was 0.9% (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 rates far below international benchmarks. A review of the literature suggests that endophthalmitis rates around the world range from 2.6% to 17%. The United States National Eye Trauma Registry has reported an endophthalmitis rate of 6.9% after open-globe repair.1

Reference: 1Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series

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

13

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.

Eye Trauma Surgery

Photo courtesy of

Matthew Gardiner, M.D.

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

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

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)

2014 (N = 118)

International Benchmark

U.S. Rate 6.9%

1.7%

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 variety of eye problems,

and subspecialty referrals for

advanced care as needed.

The most common surgery

performed at Mass. Eye and

Ear is cataract extraction with

intraocular lens implantation.

Similar results were reported

for calendar years 2010,

2011, 2012, and 2013. These

results are also consistent

with an earlier 12-month

period between July 2008

and June 2009, when data

collection began. For the past

six 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 2014 calendar year, the Comprehensive Ophthalmology and Cataract Consultation Service performed cataract surgery on 1,927 eyes. This chart depicts the results of the 1,829 eyes that had at least one month of follow-up data. Of these 1,829 eyes, 1,759 (96.2%) 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, Schein

O, Schachat AP, Abbott RL, Hoskins HD,

Steinberg EP. Initial two years of experience

with the AAO National Eyecare Outcomes

Network (NEON) cataract surgery database.

Ophthalmology 2000; 107(4):691-697. 4Simon SS, Chee YE, Haddadin RI, Veldman

PB, Borboli-Gerogiannis S, et al. Achieving

target refraction after cataract surgery. Am J

Ophthalmol 2014; 121(2):440-444.

normal lens cataract or cloudy

lens

Cataract Surgery

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge w

ithi

n ra

nge

of t

arge

t re

frac

tion

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) 2014 (N = 1,829)


*July 2008-June 2009

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


Comprehensive Ophthalmology

Service has some of the lowest

intraoperative complication

rates compared to international

benchmarks.

15

Cataract Surgery: Intraoperative Complication Rates

Of the 1,927 cataract surgeries performed by the Comprehensive Ophthalmology and Cataract Consultation Service during the 2014 calendar year at all surgical locations, only 32 (1.7%) had intraoperative complications. These results are displayed in the graph above. Similar results were reported in calendar years 2012 and 2013, during which only 36/1,464 (2.5%) and 44/1,719 (2.6%) of cataract surgeries, respectively, had intraoperative complications.

Mass. Eye and Ear 2014 Intraoperative Complication Rates:Descemet tear: 1/1,927 (0.05%)Posterior capsule tear and/or vitreous loss: 20/1,927 (1.0%)Dropped lens/retained lens fragment: 6/1,927 (0.3%)Zonular dialysis: 5/1,927 (0.3%)

International Benchmarks:1-5

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

References: 1Greenberg PB, Tseng VL, Wu WC, Liu J, Jiang L, et al. Prevalence and predictors of ocular complications associated

with cataract surgery in United States veterans. Ophthalmology 2011; 118(3): 507-514. 2Haripriya A, Chang DF, Reena M,

Shekhar M. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J

Cataract Refract Surg 2012; 38(8): 1360-1369. 3Pingree MF, Crandall AS, Olson RJ. Cataract surgery complications in 1 year at an

academic institution. J Cataract Refract Surg 1999; 25(5): 705-708. 4Ng DT, Rowe NA, Francis IC, Kappagoda MB, Haylen MJ, 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) 2014 (N = 1,927) International Benchmark

Descemet tear PC tear and/or vitreous loss

Dropped lens/retained lens fragment

Zonular dialysis

0.2% 0.3% 0.05%

1.7% 1.6%1.0%

0.3% 0.3% 0.3%0.2% 0.2%0.5%

0% to 0.9%

0.3% to 4.4%

0% to 1.7%

0.1% to 1.2%

The Retina Service at Mass.

Eye and Ear is one of the

largest subspecialty groups

of its kind in the country. Our

clinicians are highly skilled at

diagnosing and treating a full

range of ocular conditions,

including macular degeneration,

diabetic retinopathy, retinal

detachments, ocular tumors,

intraocular infections, and

severe ocular injuries.

These single surgery success

rates are comparable to

international benchmarks

reported in the literature, which

range from 59% to 95% for

primary rhegmatogenous retinal

detachment repair.1-5

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 that require surgical repair by the Mass. Eye and Ear Retina Service. During calendar year 2014, the Retina Service performed surgical procedures to repair rhegmatogenous retinal detachments that 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. Of a total of 221 eyes with primary rhegmatogenous retinal detachment, 175 (79.2%) of the retinas were successfully reattached after one surgery at three months or greater of follow-up. Similar results were reported for calendar years 2012 and 2013, when 138/173 (80.0%) and 168/220 (76.4%) of retinas, respectively, were successfully reattached after the first surgery. 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, Hainsworth DP, Almony A. Surgical management of

rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials.

Ophthalmology 2013; 120(7): 1440-1447. 2Feltgen N, Heinrich H, Hoerauf H, Walter P,

Hilgers RD, 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(3):282-287. 3Adelman RA, Parnes AJ, Ducournau D,

European Vitreo-Retinal Society (EVRS) Retinal Detachment Study Group. Strategy for

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

Society retinal detachment study report 1. Ophthalmology 2013; 120(9): 1804-1808. 4Sodhi A, Leung LS, Do DV, Gower EW, Schein OD, Handa JT. Recent trends in the

management of rhegmatogenous retinal detachment. Surv Ophthalmol 2008; 53(1):50-

67. 5Day S, Grossman DS, Mruthyunjaya P, Sloan FA, Lee PP. 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)

2014 (N = 221)


80.0%76.4% 79.2%

With a 100% 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

Retinal reattachment was successfully achieved in all 221 eyes with a primary rhegmatogenous retinal detachment during calendar year 2014. This success rate reflects eyes that had one or more surgeries, which may have included pars plana vitrectomy, scleral buckle, and pneumatic retinopexy. These 221 eyes had at least three months of follow-up from the date of the last surgery. The smaller number of cases in calendar year 2010 may be attributable to more stringent follow-up criteria of having at least five months of follow-up data.

References: 1Han DP, Mohsin NC, Guse CE, Hartz A, Tarkanian

CN, Southeastern Wisconsin Pneumatic Retinopexy Study Group.

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, Bartolotta G, Torrisi

B, Reibaldi A. 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, Chanana B, Sharma YR, Vohra R. Primary

vitrectomy versus conventional retinal detachment surgery in phakic

rhegmatogenous retinal detachment. Acta Ophthalmol Scand 2007;

85(5): 540-545. 4Sullivan PM, Luff AJ, Aylward GW. Results of primary

retinal reattachment surgery: a prospective audit. Eye 1997; 11(Pt 6):

869-871. 5Day S, Grossman DS, Mruthyunjaya P, Sloan FA, Lee PP.

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% 100.0%

97% to 100%1-5

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

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

2013 (N = 220) 2014 (N = 221)


*March 2008-February 2009

Macular Hole Surgery: Single Surgery Success Rate at Three Months

During calendar year 2014, the Mass. Eye and Ear Retina Service treated 24 eyes of 22 patients with first onset, acute, non-traumatic macular holes. A total of 27 surgeries (including pars plana vitrectomy, membrane peel, and gas tamponade) were performed on 24 eyes. The single surgery success rate for macular hole closure was determined for primary, uncomplicated macular holes of less than six months duration. Of the 24 eyes that underwent primary macular hole surgery in 2014, 22 eyes (91.7%) achieved surgical success with a single operation. Success was defined as any primary macular hole that remained fully closed for longer than three months after the first surgery. Similar results were reported in calendar year 2013, during which time 33 eyes (93.9%) 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, Lawrence Y, Lai M, Capone A Jr., Williams GA. Surgical outcomes

of idiopathic macular hole repair with limited postoperative positioning. Retina 2011;

31(3): 609-611. 2Smiddy WE, William F, Ghassan C. Internal limiting membrane peeling in

macular hole surgery. Ophthalmology 2001; 108(8): 1471-1478. 3Guillaubey A, Malvitte L,

Lafontaine PO, Jay N, Hubert I, Bron A, Berrod JP, Creuzot-Garcher C. Comparison of face-

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

Am J Ophthamol 2008; 146(1): 128-134.

89.8% to 93%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% 91.7%

2012 (N = 29)

2013 (N = 33)

2014 (N = 24)

National Benchmark

During the 2014 calendar year, the Mass. Eye and Ear Retina Service performed 8,853 intravitreal injections. Of these, two cases of endophthalmitis after intravitreal injection were identified. In one case of acute endophthalmitis, the patient presented five days after the injection with anterior chamber inflammation and seven days after the injection with vitreous cells. The patient underwent a vitreous tap with injection of intravitreal antibiotics. Vitreous cultures showed no growth. At six months follow-up after treatment, best corrected visual acuity returned to the patient’s baseline vision of “counting fingers” (CF). In the second case, the patient presented with a hypopyon and vitreous debris five days after the injection. Anterior chamber and vitreous taps were performed with injections of antibiotics. The vitreous culture was negative, but the anterior chamber culture revealed Staphylococcus lugdunensis. The patient’s baseline vision was 20/30, but at 4 months follow-up, the best corrected visual acuity was 20/80.

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, 2014. During this six-year period, 29,903 intravitreal injections were performed by the Mass. Eye and Ear Retina Service. The rate of endophthalmitis after intravitreal injection during this six-year period was 0.02% (five out of 29,903 injections).

References: 1Bhavsar AR, Googe JM Jr, Stockdale CR, Bressler NM, Brucker AJ, et al. Risk of endophthalmitis after intravitreal

drug injection when topical antibiotics are not required. Arch Ophthalmol 2009; 127(12): 1581-1583. 2Englander M, Chen

TC, Paschalis EI, Miller JW, Kim IK. 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, Lindsley K, Vedula SS,

Krzystolik MG, Hawkins BS. Metaanalysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial

growth factor agents. Ophthalmic Surg Lasers Imaging Retina 2014; 45:143-149. 4VanderBeek BL, Bonaffini SG, Ma L. Association

of compounded bevacizumab with postinjection endophthalmitis. JAMA Ophthalmol 2015; 133:1159-64. 5Dossarps D, Bron

AM, Koehrer P, Aho-Glélé LS, Creuzot-Garcher C, FRCR net (FRenCh Retina specialists net). Endophthalmitis after intravitreal

injections: incidence, presentation, management, and visual outcome. Am J Ophthalmol 2015; 160:17-25.

18

Acute endophthalmitis is a

rare potential complication

of intravitreal injections.

Mass. Eye and Ear’s rates of

endophthalmitis after intravitreal

injection are among the lowest

compared to international

benchmarks.

10

9

8

7

6

5

4

3

2

1

00.00% 0.05% 0.00% 0.03% 0.02%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) 2014 (N = 8,853)


The Ocular Melanoma Center at

Mass. Eye and Ear, co-directed

by Evangelos Gragoudas, M.D.,

and Ivana Kim, 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: Ocular Melanoma Center – 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 Before receiving radiation treatment for uveal melanoma, most patients have tantalum ring surgery to localize the tumor. Perforation of the globe is a potential complication during tumor localization surgery. During calendar year 2014, the Ocular Melanoma Center at Mass. Eye and Ear performed tantalum ring surgery in preparation for proton beam irradiation on 105 eyes. Zero cases of globe perforation from surgery were reported. There were also no cases of globe perforation reported in 2012 and 2013.

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% 0%

Perc

enta

ge o

f gl

obe

perf

orat

ions

2012 (N = 99)

2013 (N = 101)

2014 (N = 105)

(left) Photograph of

endophthalmitis

Photo courtesy of Lucy H. Young,

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

Retina Surgery

P R E S S U R E

Glaucoma Surgery: Trabeculectomy and Tube Shunt Infection Rates

The most common incisional surgeries performed at all surgical locations by Mass. Eye and Ear Glaucoma Consultation Service are trabeculectomy and tube shunt surgery. The Mass. Eye and Ear Infectious Disease Service tracks all cases of infections after ocular procedures performed at Mass. Eye and Ear or at any of its affiliates. During the 2014 calendar year, the Glaucoma Consultation Service performed a total of 316 trabeculectomy and tube shunt surgeries. These surgeries included trabeculectomy (with or without previous scarring) on 128 eyes, and tube shunt surgeries (primary or revision) on 188 eyes. These procedures may have been combined with other procedures, such as cataract extraction or keratoprosthesis surgery. No cases of endophthalmitis were reported within 3 months after the surgery, and similar rates have been reported since data collection began in calendar year 2010. With regard to trabeculectomy and tube shunt infection rates, the optimum goal is to achieve an infection rate of 0% 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, Varga Z, Shaarawy T. 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% 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)

2014 (N = 316)


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 five 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


Glaucoma Consultation Service

continues to maintain among

the lowest 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

Aqueousmisdirection

Of the 215 cases of trabeculectomy surgery or glaucoma implant surgery performed by the Glaucoma Consultation Service during the 2014 calendar year, 98.6% (212/215) of patients had no intraoperative complications. The cases analyzed include only the trabeculectomy or implant surgeries that were not combined with cataract surgery, secondary lens implantation, or keratoprosthesis procedures. Similar results were reported for calendar years 2010, 2011, 2012, and 2013, during which time 95.5% (234/245), 99.6% (269/270), 97.2% (314/323), and 98.6% (214/217) 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 2014 complication rates:Conjunctival tear/buttonhole: 0.5%Hyphema: 0%Scleral flap trauma: 0.5%Vitreous loss (vitreous prolapse): 0%Suprachoroidal hemorrhage: 0%Scleral perforation: 0%Aqueous misdirection: 0.5%

The 215 cases evaluated included:65 trabeculectomies without scarring15 trabeculectomies with previous scarring118 primary tube surgeries17 tube revisions

References: 1Barton K, Gedde SJ, Budenz DL, Feuer WJ, Schiffman J; Ahmed Baerveldt Comparison Study Group. The Ahmed

Baerveldt Comparison Study methodology, baseline patient characteristics, and intraoperative complications. Ophthalmology

2011; 118(3): 435-442. 2Jampel HD, Musch DC, Gillespie BW, Lichter PR, Wright MM, et al. Perioperative complications of

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

SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC.. 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, Tsai JC, Zurakowski D, Kalenak

JW, Cantor LB, Ahmed II. The Ahmed Versus Baerveldt Study: design, baseline patient characteristics, and intraoperative

complications. Ophthalmology 2011; 118(11): 2172-2179. 5Kirwan JF, Lockwood AJ, Shah P, Macleod A, Broadway DC et al.

Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology 2013; 120(12):2532-2539.

International benchmarks:1-5

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%Aqueous misdirection: 0.2%-1.0%

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) 2014 (N = 215) International Benchmark


1.1% to 3%

1% to 8%

0.7%1% 0% to 1%

0% to 3%

0.2% to 1%

22

In summary, the Mass.

Eye and Ear Glaucoma

Consultation Service

achieves low trabeculectomy

reoperation rates.

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. In this analysis, we included only mitomycin C trabeculectomies that were not combined with cataract surgery, secondary lens implantation, or keratoprosthesis procedures. There were 74 mitomycin C trabeculectomy surgeries (with or without scarring) performed by the Glaucoma Consultation Service for the 2014 calendar year at all surgical locations. Reoperation rates were calculated at the one-month and six-month postoperative time periods. Reoperations were defined as glaucoma procedures required for further intraocular pressure lowering (i.e., repeat trabeculectomy, tube shunt surgery, diode cyclophotocoagulation). Five patients were lost to follow up at the six-month time period. In the Mass. Eye and Ear Glaucoma Consultation Service, the reoperation rate for mitomycin C trabeculectomy surgery was 0% at one month (out of 74 total procedures) and 5.8% at six months (one bleb revision, one diode cyclophotocoagulation procedure, one repeat trabeculectomy, and one tube shunt surgery in 69 patients available for follow up). 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

n

4.3%

5.8%

One Month Postoperative

(N = 93) (N = 74)

Six Months Postoperative

(N = 92) (N = 69)

2.2%

0%

2013 2014

23

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 or apraclonidine

0.5% before the laser procedure

and prednisolone 1% after

the procedure.

Glaucoma Laser Surgery: Intraocular Pressure (IOP) Spikes

During calendar year 2014, the Glaucoma Consultation Service performed anterior segment laser procedures on 765 eyes. Of the 765 eyes, this analysis includes the 591 eyes that had laser peripheral iridotomies (254), capsulotomies (46) and laser trabeculoplasties (291). Of the 291 laser trabeculoplasties, 58 were argon laser trabeculoplasties (ALT) and 233 were selective laser trabeculoplasties (SLT).

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

Laser peripheral iridotomy: 24.0% 0% to 35% 4.7% 0%

Capsulotomy: 8.7% 5.7% to 13% 0% 0.02% to 4%

Laser trabeculoplasty: 21.3% 7% to 10.3% 5.2% 3%

Overall: 21.5% 0% to 31.7% 4.6% 0% to 9.8%

References: 1Chevier RL, Assalian A, Duperré J, Lesk MR. Apraclonidine 0.5% versus brimonidine 0.2% for the control of intraocular

pressure elevation following anterior segment laser procedure. Ophthalmic Surg Lasers 1999; 30(3): 199-204. 2Yuen NS, Cheung P, Hui

SP. 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(2): 89-92. 3Yeom HY, Lee JH, Hong YJ, Seong GJ. Brimonidine 0.2%

versus brimonidine purite 0.15%: prophylactic effect on IOP elevation after Nd:YAG laser posterior capsulotomy. J Ocul Pharmacol

Ther 2006; 22(3): 176-181. 4Collum RD Jr, Schwartz LW. The effect of apraclonidine on the intraocular pressure of glaucoma patients

following Nd:YAG laser posterior capsulotomy. Ophthalmic Surg 1993: 24(9): 623-626. 5Lai JS, Chua JK, Tham CC, Lam DS. Five-year

follow-up of selective laser trabeculoplasty in Chinese eyes. Clin Experiment Ophthalmol 2004; 32(4): 368-372. 6Francis BA, Ianchulev

T, Schofield JK, Minckler DS. Selective laser traeculoplasty as a replacement for medical therapy in open-angle glaucoma. Am J

Ophthalmol 2005; 140:524-525. 7Chen TC, Ang RT, Grosskreutz CL, Pasquale LR, Fan JT. Brimonidine 0.2% versus apraclonidine

0.5% for prevention of intraocular pressure elevations after anterior segment laser surgery. Ophthalmology 2001; 108(6):1033-1038. 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, Song KY, Park WH, Sohn YH. Effect of apraclonidine hydrochlo-

ride 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) 2014 (N = 591) International Benchmark

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 2014 calendar

year, 197 of the 250 eyes

that had LASIK surgery had

sufficient follow-up data for

analysis. Sufficient follow-

up was defined as at least

one month for myopia, and

at least three months for

hyperopia.

In calendar year 2014,

the overall LASIK success

rate for achieving within 0.5

diopters of target refraction

for myopia and hyperopia

was 87.3% (172/197 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 2014 calendar year, 165 of the 214 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 89.1% (147/165 eyes) for calendar year 2014. Benchmark data from U.S. Food and Drug Administration (FDA) trials of 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 six 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, Chan WK, Koh J, Mehta JS,

Tan DT; SingLasik Research Group. 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% 89.1%

70% to 83%1-2

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

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

2013 (N = 212) 2014 (N = 165)



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 2014, 165 of the 214 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 56 eyes, and of these, 91.1% (51/56 eyes) were successful. For the 93 eyes with moderate myopia, 89.2% (83/93 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 2010, 2011, 2012, and 2013 calendar years, during which time the success rate for low myopia was 91.5% (86/94 eyes), 97.3% (71/73 eyes), 90.4% (75/83 eyes), and 95% (76/80 eyes), respectively. Moderate myopia success rates were consistent for 2010, 2011, 2012, and 2013 with 85.4% (105/123 eyes), 82.1% (128/156 eyes), 91.2% (145/159 eyes), and 87.9% (102/116 eyes), respectively. Results for LASIK for high myopia ranged between 80% (28/35 eyes) in 2010, 96.8% (30/31 eyes) in 2011, 75.9% (22/29 eyes) in 2012, and 81.3% (13/16 eyes) in 2013. 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) 2014 (N = 165)


86.1

91.5

97.3

90.4

95.091.1

87.885.4

82.1

91.287.9 89.2

81.3 80.0

96.8

75.9

81.3 81.3

26

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

79.3%85.0%

77.8%

68.0%

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge w

ithi

n 0.

5 di

opte

rs o

f ta

rget

ref

ract

ion

Of the 36 eyes that had LASIK surgery for hyperopia during the 2014 calendar year, 32 had three months or more of follow-up data for analysis. The overall 2014 LASIK success rate for achieving within 0.5 diopters of target refraction was 78.1% (25/32 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: 1Alió JL, El Aswad A, Vega-Estrada A,

Javaloy J. Laser in situ keratomileusis for high hyperopia

(>5.0 diopters) using optimized aspheric profiles:

efficacy and safety. J Cataract Refract Surg 2013; 39(4):

519-527. 2Keir NJ, Simpson T, Hutchings N, Jones L,

Fonn D. 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%78.1%

66.7% to 91%1-3

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

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

2013 (N = 36) 2014 (N = 32)



For the past five years, the

Mass. Eye and Ear Cornea and

Refractive Surgery Service has

maintained low enhancement/

retreatment rates when


benchmarks.

For the past six 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 197 eyes that had LASIK surgery for myopia or hyperopia during the 2014 calendar year, 6.1% (12/197) 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, Fares U, Dua HS.

Re-treatment after laser in situ keratomileusis for

correction of myopia and myopic astigmatism. Br J

Ophthalmol 2008; 92(11): 1506-1511. 2Yuen LH,

Chan WK, Koh J, Mehta JS, Tan DT; SingLasik Research

Group. 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. 3Alió

JL, El Aswad A, Vega-Estrada A, Javaloy J. Laser in situ

keratomileusis for high hyperopia (>5.0 diopters) using

optimized aspheric profiles: efficacy and safety. J Cataract

Refract Surg 2013; 39(4): 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% 6.1%

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

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

2014 (N = 197) International Benchmark

2.7%

(left) Photograph of

keratoprosthesis (KPro)

Photo courtesy of

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

27

Cornea Surgery:Keratoprosthesis (KPro)

The Boston Keratoprosthesis (KPro) is an artificial cornea developed at Mass. Eye and Ear by Claes Dohlman, M.D., Ph.D. and colleagues. Dr. Dohlman is former Chief of Ophthalmology at Mass. Eye and Ear and Chair of the Department of Ophthalmology at Harvard Medical School. Dr. Dohlman is currently Emeritus Professor of Ophthalmology at Harvard Medical School. In development since the 1960s, the KPro received FDA clearance in 1992 and European Conformity (CE) mark approval in 2014. It is the most common-ly used artificial cornea in the world with more than 11,000 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 = 17

Keratoprosthesis Surgery: Surgical Indications

Twenty-seven patients received the type 1 Boston Keratoprosthesis (KPro) during calendar year 2014. Of these 27 patients, 17 (63.0%) received a KPro for the first time and are included in this analysis. Similar data were reported for calendar year 2013, during which time 37 patients received a type 1 KPro, with 29 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 (9/17, 52.9%), corneal neovascularization and scarring (5/17, 29.4%), aniridic keratopathy (2/17, 11.8%), and hypotony and corneal edema (1/17, 5.9%). Seven patients (7/17, 41.2%) received the KPro as a primary procedure. One aniridic eye had a prior failed graft but was classified only in the aniridic keratopathy category. Corneal neovascularization and scarring were present in one eye from Stevens-Johnson syndrome, and in another eye due to herpes zoster.

Reference: 1Ament JD, Stryjewski TP, Ciolino

JB, Todani A, Chodosh J, Dohlman CH. Cost-

effectiveness of the Boston Keratoprosthesis. Am J

Ophthalmol 2010; 149(2): 221-228.

Failed Graft 52.9%

AniridicKeratopathy11.8%

Hypotony andCorneal Edema5.9%

Corneal Neovascularization and Scarring29.4%

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

28

Keratoprosthesis Surgery: Visual Outcomes

Keratoprosthesis Surgery: Retention Rates

100

90

80

70

60

50

40

30

20

10

0

Perc

enta

ge

Of the 17 primary type 1 Boston Keratoprosthesis (KPro) surgeries in calendar year 2014 for which three months of follow-up data were available, 100% of patients retained the KPro at three months. Similar results (100% KPro retention at three months) were reported for calendar years 2011, 2012, and 2013. Per the literature, expected retention rates range from 90.5% to 95% of patients.1-2

References: 1Kang JJ, de la Cruz J, Cortina MS. Visual outcomes of

Boston keratoprosthesis implantation as the primary penetrating

corneal procedure. Cornea 2012; 31(12):1436-40. 2Zerbe BL,

Berlin MW, Ciolino JB, Boston Type 1 Keratoprosthesis Study

Group. Results from the multicenter Boston type I keratoprosthesis

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

100% 100% 100% 100%

90.5% to 95%1-2

2011 (N = 27) 2012 (N = 25)

2013 (N = 29) 2014 (N = 17)

National Benchmark

2011 (N = 27) 2012 (N = 25)

2013 (N = 29) 2014 (N = 17)

National Benchmark

During calendar year 2014, 17 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 17 patients, 13 (76.5%) 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

Four patients did not achieve postoperative vision of 20/200 or better, and in each case the visual prognosis was limited due to pre-existing severe retinal disease or advanced glaucoma.

References: 1Kang JJ, de la Cruz J, Cortina MS. Visual outcomes of

Boston keratoprosthesis implantation as the primary penetrating

corneal procedure. Cornea 2012; 31(12):1436-40. 2Zerbe BL,

Berlin MW, Ciolino JB. Results from the multicenter Boston type

I keratoprosthesis study. Ophthalmology 2006; 113(1): 1779.

e1-1779.e7. 3Greiner MA, Li JY, Mannis MJ. Longer-term vision

outcomes and complications with the Boston type 1 keratoprosthesis

at the University of California, Davis. Ophthalmology 2011; 118(8):

1543-1550.

56% to 89%1-3

20/200 or better

66.7%

84%

76% 76.5%

(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

Tracked for the first time

in calendar year 2014, the

novel Descemet’s membrane

endothelial keratoplasty

(DMEK) procedure is now

increasingly performed

at Mass. Eye and Ear for

the treatment of corneal

endothelial disorders.

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

During the 2014 calendar year, the Mass. Eye and Ear Cornea Service performed 258 keratoplasty procedures; of these, 122 (47.3%) were full-thickness penetrating keratoplasty (PK) procedures, and 136 (52.7%) were partial-thickness lamellar keratoplasties. The distribution analysis excluded 39 PKs that were done in combination with retinal, glaucoma, or keratoprosthesis (KPro) procedures, as well as 26 therapeutic PKs done for active infection or non-healing ulcers. This left 57 PKs for inclusion in the distribution analysis compared to 136 partial-thickness procedures: 106 Descemet’s stripping endothelial keratoplasties (DSEKs), 14 Descemet’s membrane endothelial keratoplasties (DMEKs), and 16 deep anterior lamellar keratoplasties (DALKs).

N = 193

Deep AnteriorLamellar Keratoplasty(DALK)8.3%

Penetrating Keratoplasty (PK)29.5

Descemet’sStripping Endothelial Keratoplasty (DSEK)

54.9%

Descemet’s Membrane Endothelial Keratoplasty (DMEK)7.3%

30

Corneal transplant surgery

provides clear cornea tissue

from a donor to replace

diseased host tissue.

Mass. Eye and Ear PK surgery

success rates continue to

meet or exceed international

benchmarks.1-2

Cornea Surgery: Surgical Indications for Penetrating Keratoplasty (PK)

During the 2014 calendar year, 122 full-thickness penetrating keratoplasty (PK) procedures were performed by the Mass. Eye and Ear Cornea and Refractive Surgery Service. The current analysis includes only elective PKs that had up to three months of follow-up data available and were not done in combination with retinal, glaucoma, or keratoprosthesis (KPro) procedures. This left 55 (45.1%) elective PKs for analysis for calendar year 2014. These 55 elective PKs included first-time grafts in uninflamed host beds, as well as PKs performed in eyes at high risk of rejection, including eyes with extensive corneal neovascularization and/or a failed corneal graft. Indications for elective PKs included failed corneal graft (30/55, 54.5%), keratoconus (11/55, 20%), corneal scar (8/55, 14.5%), bullous keratopathy (2/55, 3.6%), corneal edema (2/55, 3.6%), and corneal dystrophy (2/55, 3.6%). One eye with keratoconus also had Fuch’s endothelial dystrophy and was classified under keratoconus.

N = 55

BullousKeratopathy

3.6% Corneal Edema3.6%

Corneal Scar14.5%

Keratoconus20.0%

Failed Corneal

Graft54.5%

Corneal Dystrophy3.6%

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

Of 122 full-thickness PKs performed in 2014, 55 were elective procedures with up to three months follow-up data and included in the analysis. Of these elective PKs, 51 (92.7%) achieved surgical success, which is defined as a graft at three months follow-up with minimal to no clinical edema and with sufficient clarity to permit the examiner to have an unencumbered view of the interior of the eye, including iris details.

References: 1Vail A, Gore SM, Bradley BA, Easty

DL, Rogers CA. Corneal graft survival and visual

outcome: a multicenter study. Ophthalmology 1994;

101(1): 120-127. 2Price MO, Thompson Jr. MD, Price

Jr. FW. Risk factors for various causes of failure in

initial corneal grafts. Arch Ophthalmol 2003; 121(8):

1087-1092.

93.0% 92.8%98.3% 98.3%

92.7%

92.5% to 95%1-2

96.8%

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

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

2013 (N = 58) 2014 (N = 55)


*July 2008-July 2009

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

25

20

15

10

5

0

Reo

pera

tion

rat

e af

ter

exte

rnal

DC

R s

urge

ry (

%)

During the 2014 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed external dacryocystorhinostomy (Ex-DCR) procedures on 66 eyes of 62 patients. Twelve eyes of 11 patients were excluded for pre-existing ocular conditions, such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), benign tumors, post-traumatic lacrimal obstruction, congenital cases, and cases with sinus disease (e.g., sinusitis). This analysis includes the remaining 54 eyes of 51 patients who underwent primary Ex-DCR in 2014 for primary acquired nasolacrimal duct obstruction (NLDO). Of these eyes, none (0%) 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 a common surgical method for NLDO. A review of the literature suggests that 7.8% to 12.5% of patients require reoperation following primary external 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, Ghabrial R, Lynch TF, Tang B. A comparison of external and endoscopic

dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clinical

Ophthalmology 2011; 5: 979-989. 3Ben Simon GJ, Joseph J, Lee S, Schwarcz RM,

McCann JD, Goldberg RA. 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)

2014 (N = 54)


0.0% 0.0%

1.8%

31

Oculoplastic Surgery: Dacryocystorhinostomy (DCR) Lacrimal Bypass Surgery

For the past three years, the

Mass. Eye and Ear Ophthalmic

Plastic Surgery Service has

maintained a low reoperation

rate for Ex-DCR surgeries


benchmarks.

Dacryocystorhinostomy (DCR)

is a surgery that aims to

improve tear drainage from the

lacrimal sac to the nose.

Lacrimal gland

Canaliculus

Lacrimal sac

DCR ostium site

Nasolacrimal duct

2% to 11%1-4

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

32

In contrast to conventional

external DCR (Ex-DCR),

En-DCR is a minimally invasive

procedure that is possible due

to technological advances in

instruments of rhinologic surgery.

This analysis includes En-DCR

procedures done in patients

with underlying sinus disease or

other intranasal abnormality such

as significant septal deviation.

These procedures, representing

approximately half of all En-DCR

procedures reported for 2014,

were done in collaboration with

the Mass. Eye and Ear Rhinology

Division.


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 2014 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed upper lid blepharoplasty and/or ptosis repair surgeries on 540 eyelids in 305 patients. These lid surgeries included (but were not limited to) functional eyelid surgery, cosmetic eyelid surgery, and surgeries on patients with other medical conditions, such as neurogenic ptosis, myogenic ptosis, congenital ptosis, and thyroid eye disease. Of these 540 eyelids, only 2.8% (15/540) required a second procedure within six months in order to achieve surgical success. Similar results were reported for calendar years 2011, 2012, and 2013, during which time 2.6% (11/416), 1.7% (8/467), and 3.1% (18/574) of eyelids required a second procedure within six months, respectively. 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, Chadha V, Bunce C, Olver JM, Wright

M. 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.Springer; 2011, 269-274.

2.6% to 8.7%1-2

2009 (N = 343)*

2011 (N = 416) 2012 (N = 467)

2013 (N = 574) 2014 (N = 540)


*March 2008-February 2009

2.9% 2.6%1.7%

3.1% 2.8%

25

20

15

10

5

0

Reo

pera

tion

rat

e af

ter

endo

scop

ic D

CR

sur

gery

(%

)

During the 2014 calendar year, the Mass. Eye and Ear Ophthalmic Plastic Surgery Service performed endoscopic dacryocystorhinostomy (En-DCR) procedures on 45 eyes of 36 patients. Seventeen eyes of 15 patients were excluded for pre-existing ocular conditions, such as Wegener’s granulomatosis, sarcoidosis, cancer (e.g., lymphoma), benign tumors, post-traumatic lacrimal obstruction, and congenital cases. Procedures involving laser DCR were also excluded. This analysis includes the remaining 28 eyes of 21 patients who underwent primary En-DCR in 2014 for primary acquired nasolacrimal duct obstruction (NLDO). Of these eyes, 7.1% (2/28) 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 NLDO require a revision.1-4

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

dacryocystorhinostomy. Ophthalmology 2003; 110: 78-84. 2Ben Simon GJ, Joseph J, Lee S,

Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy

for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 2005;

112:1463-1468. 3Moore William MH, Bentley C, Olver J. Functional and anatomic results after

two types of endoscopic endonasal dacryocystorhinostomy. Ophthalmology 2002; 109: 1575-

1582. 4Codere Francois, Denton P, Corona J. Endonasal dacryocystorhinostomy: a modified

technique with preservation of the nasal and lacrimal mucosa. Ophthal Plast Reconstr Surg 2010;

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

5.6%7.1%

2013 (N = 18)

2014 (N = 28)


2010 data are not available at the time of this publication

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.

References: 1Ehrenberg M, Nihalani BR, Melvin P, Cain CE, Hunter DG, Dagi LR. Goal-determined metrics to assess outcomes of

esotropia surgery. J AAPOS 2014; 18(3): 211-216.

Our goal-directed methodology

provides a clinically relevant

appraisal of strabismus surgery

outcomes. Reported results

were monitored two to six

months after strabismus

surgery was performed.

34

Indications for strabismus

surgery included restoration

of binocular vision, restitution

of normal eye contact

(reconstructive), treatment of

double vision, or reduction

of anomalous head posture

(torticollis).

Pediatric and Adult Strabismus Surgery:Outcomes Criteria

1. Goal—Binocular Potential for Esotropia (ET)

Subjective Distance angle1 Near angle

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

Good 10∆< ET≤15∆ or X(T)≤10∆ any ET

5∆< XT≤10∆

Poor Recommend re-operation 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 re-operation 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 re-operation 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

In the calendar year 2014,

there were 12 surgeries

performed to reduce torticollis;

these were included in the total

amount of strabismus surgeries

performed. However, the total

number of torticollis surgeries

was small compared to the

other objectives, and thus

precluded analysis.

35

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

Subjective

Excellent No diplopia in primary1

Good2,3 Diplopia controlled with prism

Poor Recommend re-operation 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. Preexisting 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 re-operation for diplopia or torticollis >12°

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

Pediatric and Adult Strabismus Surgery:Outcomes Criteria

36

Of the 106 patients who

underwent surgical remediation

of exotropia in 2014, 31

patients had surgery to restore

binocular vision, 70 for

reconstructive purposes, 3 to

resolve diplopia, and 2 to

resolved uncomplicated

torticollis. Exotropia patients

are grouped according to the

primary goal for surgery.

Of the 106 patients with

exotropia who underwent

strabismus surgery in 2014,

51 patients had associated

risk factors. Of the 55 patients

with no associated risk factors,

2 had surgery to resolve

uncomplicated torticollis.

Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by Goal

100

80

60

40

20

0

100

80

60

40

20

0

100

72.4

14.3

13.3

61.2

18.4

20.4

71.5

14.6

13.9

87.5

12.5

83.6

13.1

3.3

46.9

21.9

31.2

72.3

18.8

8.9

10088.6

5.75.7

54.8

16.1

29.1

77.4

13.2

9.4

Perc

enta

gePe

rcen

tage

Pediatric and Adult Strabismus Surgery: Exotropia Outcomes Stratified by 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.

The figure represents outcomes for exotropia surgery performed by ophthalmologists with joint appointments at the Mass. Eye and Ear Pediatric Ophthalmology and Strabismus Service and Boston Children’s Hospital from calendar years 2012, 2013 and 2014. 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.

%Excellent %Good %Poor *N includes surgeries performed to resolve uncomplicated torticollis (not included in analysis)


Binocular Potential

2012(N = 49)

2013(N = 32)

2014(N = 31)

2013No RiskFactors(N = 5)

2013Risk

Factors(N = 3)

2013No RiskFactors

(N = 20)

2013Risk

Factors(N = 12)


2014Risk

Factors(N = 2)

2014No Risk Factors

(N = 23)

2014Risk

Factors(N = 8)

2013No RiskFactors

(N = 25)

2013Risk

Factors(N = 36)

2013No RiskFactors

(N = 50)

2013Risk

Factors(N = 51)

2014No Risk Factors

(N = 29)

2014Risk

Factors(N = 41)

2014No RiskFactors

(N = 55)

2014Risk

Factors(N = 51)

2012(N = 98)

2013(N = 61)

2014(N = 70)

2012(N = 16)

2013(N = 8)

2014(N = 3)

2012(N = 165)

2013(N = 101)

2014(N = 106)

Diplopia

Reconstructive

Reconstructive

Diplopia

Binocular Potential

Overall

Overall

100

66.7

33.3

100 10092

77.8

93.185.4

4.99.7

30.0

25.0

45.0 50.0

16.7

33.3

13.0

26.1

60.9

37.5

37.5

25.014.0

12.0

74.070.6

5.9

23.5

7.3

16.4

76.3 78.4

9.8

11.8

2.8

19.46.94.0

4.0

Of 127 patients with esotropia

who had strabismus surgery in

2014, 46 underwent surgery to

restore binocular vision, 43 for

reconstructive goals, 28 to

resolve diplopia, and 10 to

resolve torticollis.

Of the 127 patients with

esotropia who underwent

strabismus surgery in 2014,

64 patients had associated risk

factors. Of 10 surgeries

performed to resolve torticollis,

4 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

81.8

18.2

77.8

9.7

12.5

76

10.7

13.3

77.8

8.8

13.4

92.3

7.7

80.5

11.7

7.8

75.4

10.1

14.5

80.2

7.6

12.2

92.9

7.1

90.7

4.74.6

73.9

10.9

15.2

84.3

6.3

9.4

Perc

enta

gePe

rcen

tage

Pediatric and Adult Strabismus Surgery: Esotropia Outcomes Stratified by 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.

These graphs illustrate outcomes of esotropia surgery performed by ophthalmologists with joint appointments at the Mass. Eye and Ear Pediatric Ophthalmology and Strabismus Service and Boston Children’s Hospital during calendar years 2012, 2013 and 2014. 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.



Binocular Potential

2012(N = 75)

2013(N = 69)

2014(N = 46)

2013No RiskFactors

(N = 10)

2013Risk

Factors(N = 16)

2013No RiskFactors

(N = 54)

2013Risk

Factors(N = 15)


2014Risk

Factors(N = 23)

2014No Risk Factors

(N = 35)

2014Risk

Factors(N = 11)

2013No RiskFactors

(N = 29)

2013Risk

Factors(N = 48)

2013No RiskFactors

(N = 93)

2013Risk

Factors(N = 79)

2014No Risk Factors

(N = 17)

2014Risk

Factors(N = 26)

2014No RiskFactors

(N = 63)

2014Risk

Factors(N = 64)

2012(N = 9872

2013(N = 77)

2014(N = 43)

2012(N = 22)

2013(N = 26)

2014(N = 28)

2012(N = 171)

2013(N = 172)

2014(N = 127)

Diplopia

Reconstructive

Reconstructive

Diplopia

Binocular Potential

Overall

Overall

10087.5

12.5

10091.3

8.7

79.3

10.3

10.4

81.2

6.3

12.5

94.1

5.9

88.4

3.97.7

77.8

9.3

12.9

66.7

13.3

20.0

77.1

2.9

20.0

63.6

36.4

80.6

8.6

10.8

79.8

6.3

13.9

84.1

11.1

4.8

84.4

7.8

7.8

38

Of the 578 procedures

performed for strabismus, one

(0.17%) was complicated by

postoperative infection within

30 days of the procedure. There

were no cases of associated

vision loss.

Of the 578 strabismus

procedures performed, there

were no scleral perforations.

Pediatric and Adult Strabismus Surgery: Scleral Perforation During Strabismus Surgery

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

5.00

4.00

3.00

2.00

1.00

0.00

5.00

4.00

3.00

2.00

1.00

0.00

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. The following figure demonstrates the scleral perforation rate for strabismus surgery performed by ophthalmologists with joint appointments at the Mass. Eye and Ear Pediatric Ophthalmology and Strabismus Service and Boston Children’s Hospital during calendar year 2014.

References: 1Bradbury JA. What information can we give to the patient about the risks of

strabismus surgery. Eye (Lond) 2015; 29(2):252-257. 2Awad AH, Mullaney PB, AI-Hazmi

A, Al-Turkmani S, Wheeler D, et al. Recognized globe perforation during strabismus

surgery: incidence, risk factors and sequelae. J AAPOS 2000; 4(3): 150-153. 3Morris RJ,

Rosen PH, Fells P. Incidence of inadvertent globe perforation during strabismus surgery. Br

J Ophthalmol 1990; 74(8): 490-493.

Intra- or extraocular surgery may be complicated by postoperative infection. The following figure demonstrates the postoperative infection rates for strabismus, pediatric cataract, and pediatric ptosis surgeries performed by ophthalmologists with joint appointments at the Mass. Eye and Ear Pediatric Ophthalmology and Strabismus Service and Boston Children’s Hospital during calendar year 2014. The types of infection after strabismus surgery that were included were endophthalmitis, sub-Tenon’s space abscess, subconjunctival abscess, and cellulitis. In calendar year 2014, one of the 578 strabismus procedures was complicated by a suture abscess. In calendar year 2013, three of the 350 strabismus procedures were complicated by orbital cellulitis.

References: 1Ing MR. Infection following strabismus surgery. J Ophthalmic Nurs Technol 1991; 10(5):211-214. 2Bradbury JA.

What information can we give to the patient about the risk of strabismus surgery. Eye (Lond) 2015; 29(2):252-257. 3Brenner C,

Ashwin M, Smith D, Blaser S. Sub-Tenon’s space abscess after strabismus surgery. J AAPOS 2009; 13(2):198-199. 4Bradbury JA,

Taylor RH. Severe complication of strabismus surgery. J AAPOS 2013; 17(1): 59-63. 5Haripriya A, Chang DF, Reena M, Shekhar M.

Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract

Surg.2012; 38(8): 1360-1369. 6Sharma N, Pushker N, Dada T, Vajpayee RB, Dada VK. Complications of pediatric cataract surgery

and intraocular lens implantation. J Cataract Refract Surg.1999; 25(12): 1585-1588. 7Pandey SK, Wilson ME, Trivedi RH, Izak AM,

Macky TA, et al. Pediatric cataract surgery and intraocular lens implantation: current techniques, complications, and management.

Int Ophthalmol Clin 2001; 41(3): 175-196. 8Lee EW, Holtebeck AC, Harrison AR. Infection rates in outpatient eyelid surgery.

Ophthal Plast Reconstr Surg 2009; 25(2): 109-110.

0.54%0.00%

0.9%

0.0%0.17% 0.0% 0.0% 0.0%

2013 (N = 367)

2014 (N = 578)

0.08% to 1.5%1-3

0.04% to 2.6%5-7

0.04%8

0.05-0.09%1-4

2013(N = 350)

2014(N = 578)

2013(N = 83)

2014(N = 70)

2013(N = 40)

2014(N = 40)

StrabismusSurgery

Pediatric CataractSurgery

PtosisSurgery

39

The surgical volume of the

Mass. Eye and Ear Neuro-

Ophthalmology Service has

increased from calendar year

2012 to calendar year 2014.

Neuro-Ophthalmology Service: Demographics of Adult Strabismus Surgery Patients

During the 2014 calendar year, the Mass. Eye and Ear Neuro-Ophthalmology Service

performed strabismus surgeries on 120 patients. The patients included 72 (60%) females

and 48 (40%) males. Similar results were reported for calendar years 2012 and 2013,

during which time there were 59 (53.6%) females and 51 (46.4%) males among a total

of 110 patients for calendar year 2013, and 57 (51.8%) females and 53 (48.2%) males

among a total of 110 patients for calendar year 2012.

Diplopia is one of the most

common indications for

surgical intervention at the

Mass. Eye and Ear Neuro-

Ophthalmology Service.

Neuro-Ophthalmology Service: Preoperative Symptoms in Adult Strabismus Surgery Patients

100

90

80

70

60

50

40

30

20

10

0

Perc

ent

of p

atie

nts

During the 2014 calendar year, the Mass. Eye and Ear Neuro-Ophthalmology Service performed strabismus surgeries on 120 patients. The majority of patients (84.2% or 101 patients) had diplopia preoperatively, while the minority of patients (15.8% or 19 patients) did not have diplopia. Diplopia was also a common pre-operative symptom in prior calendar years 2013 (78.2% or 86 of 110 patients) and 2012 (70% or 77 of 110 patients).

Without diplopia With diplopia

2012 (N = 110) 2013 (N = 110) 2014 (N = 120)

2012 (N = 110)

2013 (N = 110)

2014 (N = 120)

Calendar Year

Male 48%

Male 46%

Male 40%

Female 52%

Female 54%

Female 60%

40

The most common indications

for adult strabismus surgery

were congenital strabismus,

idiopathic strabismus, and

traumatic strabismus, as well as

thyroid eye disease and fourth

nerve palsy.

Neuro-Ophthalmology Service: Underlying Etiologies Associated with Adult Strabismus Surgery

The current analysis depicts the etiologies associated with adult strabismus surgery for calendar year 2014. Of the 120 strabismus surgery cases, the most common etiologies were congenital, idiopathic, or traumatic strabismus (61.7% or 74 patients). In this cohort, thyroid eye disease was a common cause (14.2% or 17 patients). Other etiologies included 4th nerve palsy (12.5% or 15 patients), 6th nerve palsy (4.2% or 5 patients) and 3rd nerve palsy (4.2% or 5 patients). Multiple cranial neuropathies were seen in 1.6% or 2 patients. One patient (0.8%) had skew deviation, and one patient (0.8%) had cerebellar degeneration.

Cerebellardegeneration

0.8% Sixth nerve palsy4.2%

Multiple cranial neuropathies1.6%

Skew deviation0.8%

Fourth nerve palsy12.5%

Thyroid eye disease14.2%

Congenital, idiopathic, or

traumatic strabismus61.7% Third nerve palsy

4.2%

Of the 120 adult strabismus

surgeries which were

performed by the Mass. Eye

and Ear Neuro-Ophthalmology

Service in calendar year 2014,

the majority of patients had

surgery on 2 muscles.

Neuro-Ophthalmology Service: Number of Muscles Operated Per Patient Having Adult Strabismus Surgery

In calendar year 2014, the Mass. Eye and Ear Neuro-Ophthalmology Service performed surgeries on a total of 254 muscles in 120 patients (average number of muscles per patient was 2.12). Of these 120 surgeries, 112 patients (93.3%) had the adjustable technique and 8 patients (6.7%) had a non-adjustable procedure that consisted of an inferior oblique myectomy. Of the 112 patients who underwent an adjustable procedure, 74 patients (66.1%) needed an adjustment in the immediate postoperative period 2-3 hours following surgery.

Calendar Year 2014

Number of muscles operated on Number of patients Percentage

1 16 13.3%

2 80 66.7%

3 18 15.0%

4 6 5.0%

41

After strabismus surgery at

the Mass. Eye and Ear Neuro-

Ophthalmology Service, most

patients (92%) were without

diplopia postoperatively, with

or without prism glasses.

Neuro-Ophthalmology Service: Success Rates for Adult Strabismus Surgery

In calendar year 2014, the Mass. Eye and Ear Neuro-Ophthalmology Service performed surgeries on a total of 120 patients. Pre-operatively, 19 patients (15.8%) were without diplopia, and 101 patients (84.2%) had diplopia. Postoperatively, 86.1% patients who had diplopia (87 of 101 patients) were without diplopia in primary position after a single surgery. In addition, 7.9% (8 of 101 patients) required a second surgery. The remaining 5.9% (6 of 101 patients) who had diplopia prior to surgery were without diplopia in primary position with prism glasses after a single surgery.

Without diplopia with prism glasses following a single surgery5.9%

Without diplopia following a single surgery86.1%

Required a second surgery7.9%

Neuro-Ophthalmology Service: Rates of Scleral Perforation During Adult Strabismus Surgery

10

8

6

4

2

0

Perc

enta

ge o

f Pa

tien

ts w

ith

Scle

ral P

erfo

rati

on

In calendar year 2014, the Mass. Eye and Ear Neuro-Ophthalmology Service performed surgeries on a total of 120 patients. Zero cases had complications during or following their surgeries. The graph below depicts the rates of intra-operative scleral perforation in calendar year 2014. Of the 120 patients who had adult strabismus surgery in 2014, zero cases (0%) were associated with intraoperative scleral perforation. These results are similar to calendar years 2012 and 2013, during which zero cases (0%) had scleral perforation during surgery.

2012 (N = 110)

2013 (N = 110)

2014 (N = 120)0% 0%0%


Neuro-Ophthalmology Service

maintains low intraoperative

and postoperative complication

rates after adult strabismus

surgery.

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 3,553 patients over 7,033 office visits during the 2014 calendar year. Of the 3,553 patients seen in 2014 by the Ocular Immunology and Uveitis Service, 684 patients (19.3%) were treated for ocular inflammation with some form of systemic medication, ranging from prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen) to oral corticosteroids (i.e., prednisone) to immunosuppressive agents (e.g., methotrexate, mycophenolate mofetil).

* Data reported for the 2012 and 2014 calendar years include all patients

seen by the Ocular Immunology and Uveitis Service at any Mass. Eye and

Ear location. For calendar year 2013 data, the graphed data depict only

patients who were seen at Mass. Eye and Ear, Main Campus, in Boston.

19.5% 19.3%

27.2%

2012 (N = 2,525)*

2013 (N = 1,724)

2014 (N = 3,553)

Treatment for uveitis (i.e.,

inflammation inside the eye)

and other ocular inflammatory

conditions requires a

multidisciplinary approach that

involves internal medicine and

ophthalmology. At the Mass.

Eye and Ear Ocular Immunology

and Uveitis Service, patients

are treated with a range of

therapies, including topical eye

drops, prescription NSAIDs, and

systemic immunosuppressive

medications. In general, the use

of systemic immunomodulatory

therapy is an indicator of

increased disease severity.

Neuro-Ophthalmology Service: Rates of Infection After Adult Strabismus Surgery

10

8

6

4

2

0

Perc

enta

ge o

f Pa

tien

ts w

ith

an In

fect

ion

The graph below depicts the rates of infection following adult strabismus surgery in calendar year 2014. Of the 120 patients who had adult strabismus surgery in 2014, zero cases (0%) developed an infection within 30 days of surgery. These results are similar to calendar years 2012 and 2013, during which zero patients (0%) were cases of infection within 30 days of surgery.

2012 (N = 110)

2013 (N = 110)

2014 (N = 120)0% 0%0%

43

Vision Rehabilitation Service: Vision-Specific Quality of Life Outcomes

Patients reported improvement

on all IVI subscales with greatest

improvement for mobility and

well-being.

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 using the following scale: (0) not at all, (1) a little, (2) a fair amount, or (3) a lot of the time. Lower scores represent better visual functioning and well-being.

Pre-Rehabilitation (N = 54)

Post-Rehabilitation (N = 54)

Total

p = 0.01

Reading

p = 0.03

Mobility

p = 0.02

Well-being

p = 0.02

1.631.29

1.54

1.14

1.55

1.15

1.57

1.19

During the 2014 calendar year, out of 547 total Vision Rehab patients, 54 (9.9%) 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, Lee PP, Pitts J, Gutierrez P, Berry S, Hays RD. Psychometric properties of the National Eye Institute

Visual Function Questionnaire (NEI-VFQ). NEI-VFQ Field Test Investigators. Arch Ophthalmol. 1998; 116(11): 1496-1504. 2Scott IU, Smiddy WE, Schiffman J, Feuer WJ, Pappas CJ. Quality of life of low-vision patients and the impact of low-vision

services. Am J Ophthalmol 1999; 128(1): 54-62. 3Kuyk T, Liu L, Elliott JL, Grubbs HE, Owsley C, et al. Health-related quality

of life following blind rehabilitation. Qual Life Res 2008; 17(4): 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 = 54)

Post-Rehabilitation (N = 54)

Previous Reported Outcome Studies2,3

General vision Near activities Mental health Role difficulties

43.147.9

41.6

49.0

39.2

50.0

41.4

47.9

Patients reported improvement

on all NEI VFQ-25 subscales

with greatest improvement for

mental health.55-57

45-66 45-54

57-66

30-38

39-46 46-59

34-43

44

100

80

60

40

20

0

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

Excellent (N = 221)

Above Average (N = 26)

Average (N = 6)

Below Average (N = 0)

Poor (N = 0) N = 253

Expl

anat

ion

of

reha

bilit

atio

n op

tion

s (%

)

87.4%

10.3%

2.4% 0.0% 0.0%

99% percent 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 continues to offer multidisciplinary Comprehensive Vision Rehabilitation tailored to each patient’s unique goals. Interventions address reading, difficulties with activities of daily living, patient safety, continued participation in activities despite vision loss, and the psychosocial adjustment to low vision. During 2014, 253 patients completed a six-question survey after their initial consultation.

Excellent (N = 235)


Average (N = 2)


Poor (N = 0) N = 253

Qua

lity

of S

ervi

ce (

%)

92.9%

6.3%0.8% 0.0% 0.0%

Vision Rehabilitation Service: Patient Satisfaction Survey

100

80

60

40

20

0

Excellent (N = 239)


Average (N = 0)


Poor (N = 0) N = 253

Ninety-six percent of patients rated the interactions with staff as “Excellent” and 4% rated the interactions as “Above Average.” No patients reported that their interactions were “Average” or “Poor.”

Inte

ract

ion

wit

h st

aff

(%)

95.6%

4.4%0.0% 0.0% 0.0%

45

Based on their own

experiences, 100% of

patients said they would

recommend the Mass. Eye

and Ear Vision Rehabilitation

Service to friends or family.

Ophthalmology Medical Staff and Practice Locations

Locations

Mass. Eye and Ear, Main Campus

243 Charles Street

Boston, MA 02114

Tel: 617-573-3202

Mass. Eye and Ear, East Bridgewater

400 N. Bedford Street

E. Bridgewater, MA 02333

Tel: 508-378-2058

Site Director, Angela Turalba, MD

Mass. Eye and Ear, Longwood

800 Huntington Ave.

Boston, MA 02115

Tel: 617-398-2947

Clinical Director of Ophthalmology,

Carolyn E. Kloek, MD

Mass. Eye and Ear, Plainville

30 Man Mar Drive Suite 2

Plainville, MA 02762

Tel: 508-695-9550

Site Director, Magdalena Krzystolik, MD

Mass. Eye and Ear, Providence

One Randall Square Suite 203

Providence, RI 02904

Tel: 401-453-4600

Site Director, Magdalena Krzystolik, MD

Mass. Eye and Ear, Stoneham

1 Montvale Avenue

Stoneham, MA 02180

Tel: 781-279-4418

Site Director, Matthew F. Gardiner, MD

Mass. Eye and Ear, Retina Consultants

3 Woodland Road Suite 210

Stoneham, MA 02180

Tel: 781-662-5520

Site Director, Deeba Husain, MD

Mass. Eye and Ear, Waltham

1601 Trapelo Road

Reservoir Place, Ste. 184

Waltham, MA 02451

Tel: 781-890-1023

Site Director, Kathryn M. Hatch, MD

Comprehensive Ophthalmology

and Cataract Consultation

Sheila Borboli-Gerogiannis, MD

Stacey C. Brauner, MD

Han-Ying Peggy Chang, MD

Sherleen H. Chen, MD, Service Director

Matthew F. Gardiner, MD

Scott H. Greenstein, MD

Kathryn M. Hatch, MD

Carolyn E. Kloek, MD

Kristine Tan Lo, MD

Alice C. Lorch, MD

Zhonghui Katie Luo, MD, PhD

George N. Papaliodis, MD

Christian E. Song, MD

Ryan A. Vasan, MD

Silas Wang, MD

Cornea and External Disease

Sheila Borboli-Gerogiannis, MD

Han-Ying Peggy Chang, MD

James Chodosh, MD, MPH, Associate

Service Director

Joseph B. Ciolino, MD

Reza Dana, MD, MSc, MPH, Service Director

Claes H. Dohlman, MD, PhD


Deborah S. Jacobs, MD

Ula V. Jurkunas, MD


Samir A. Melki, MD, PhD

Roberto Pineda II, MD

Hajirah N. Saeed, MD

Jonathan Talamo, MD

Peter B. Veldman, MD

Emergency Ophthalmology &

Eye Trauma, Emergency Department

Matthew F. Gardiner, MD, Service Director

Maggie B. Hymowitz, MD

Eye Trauma Appointments

Seanna Grob, MD, Service Director

46

47

Glaucoma

Teresa C. Chen, MD

Iryna A. Falkenstein, MD

Cynthia L. Grosskreutz, MD, PhD

Ambika S. Hoguet, MD

Milica Margeta, MD, PhD

Louis R. Pasquale, MD, Service Director

Veena Rao, MD, MSc

Lucy Q. Shen, MD

Brian J. Song, MD

Angela V. Turalba, MD, Associate

Service Director

Janey L. Wiggs, MD, PhD

Neuro-Ophthalmology

and Adult Strabismus

Dean M. Cestari, MD

John W. Gittinger, Jr., MD

Robert Mallery, MD

Joseph F. Rizzo III, MD, Service Director

Ocular Oncology

Suzanne K. Freitag, MD

Evangelos S. Gragoudas, MD

Frederick A. Jakobiec, MD, DSc

Ivana K. Kim, MD

Nahyoung Grace Lee, MD

Shizuo Mukai, MD

Francis Sutula, MD

Michael K. Yoon, MD

Ophthalmic Pathology

Thaddeus P. Dryja, MD

Frederick A. Jakobiec, MD, DSc,

Service Director

Rebecca C. Stacy, MD, PhD,

Associate Director

Ophthalmic Plastic Surgery

Suzanne K. Freitag, MD, Service Director

Nahyoung Grace Lee, MD

Daniel R. Lefebvre, MD

Francis C. Sutula, MD

Michael K. Yoon, MD

Optometry/Contact Lens

Mark M. Bernardo, OD

Shannon Bligdon, OD

Matt Goodman, OD

Yan Jiang, OD, PhD

Charles D. Leahy, OD, MS

Brittney J. Mazza, OD

Amy Scally, OD

Amy C. Watts, OD, Service Director

Karen L. Zar, OD

Vision Care for the Deaf

Andrew D. Baker, OD

Pediatric Ophthalmology and Strabismus

(in collaboration with

Boston Children’s Hospital)

Anna Maria Baglieri, OD

Kimberley Chan, OD

Linda R. Dagi, MD

Bharti Gangwani, MD

Gena Heidary, MD, PhD

Melanie A. Kazlas, MD,

Service Director, Mass. Eye and Ear

Danielle M. Ledoux, MD

Jason Mantagos, MD

Robert A. Petersen, MD, DMSc

Ankoor S. Shah, MD, PhD

Mary C. Whitman, MD, PhD

Carolyn S. Wu, MD, PhD

Refractive Surgery


Ula V. Jurkunas, MD


Samir A. Melki, MD, PhD

Roberto Pineda II, MD, Service Director

Hajirah N. Saeed, MD

Christian E. Song, MD

Retina

Jason I. Comander, MD, PhD

Dean Eliott, MD, Associate

Service Director

Evangelos S. Gragoudas, MD, Service Director

Paul B. Greenberg, MD

Rachel Huckfeldt, MD, PhD

Deeba Husain, MD

Ivana K. Kim, MD

Leo A. Kim, MD, PhD

Magdalena Krzystolik, MD

Jan A. Kylstra, MD

John I. Loewenstein, MD

Joan W. Miller, MD

John B. Miller, MD

Shizuo Mukai, MD

Eric A. Pierce, MD, PhD

Lucia Sobrin, MD, MPH

Demetrios G. Vavvas, MD, PhD

Richard Watson, MD

David M. Wu, MD, PhD

Yoshihiro Yonekawa, MD

Lucy H. Y. Young, MD, PhD

Inherited Retinal Disorders

Jason I. Comander, MD, PhD

Brian Hafler, MD, PhD

Rachel Huckfeldt, MD, PhD

Eric A. Pierce, MD, PhD, Service Director

Uveitis and Immunology

Reza Dana, MD, MSc, MPH

George N. Papaliodis, MD, Service Director

Lucia Sobrin, MD, MPH

Lucy H. Y. Young, MD, PhD

Vision Rehabilitation

Calliope Galatis, OD

Kevin E. Houston, OD

Amy Watts, OD, Service Director

Contributors

Elizabeth Acosta

Olumuyiwa Adebona

Shakhsanam Aliyeva

Bilal Alwattar

John Anderson

Christopher Andreoli

Olamide Awosanya

Sandra Baptista-Pires

Patricia Barthelemy

Linda Belkner

Cobi Ben-David

Jean Bibeau

Bridget Boles

Sheila Borboli-Gerogiannis

Stacey Brauner

Monica Bynoe

Chris Buliga

Charlene Callahan

Joel Carusone

Dean Cestari

Kenneth Chang

Peggy Chang

Wendy Chao

Yewlin Chee

Sherleen Chen

Teresa Chen

Sal Chiev

James Chodosh

Catherine Choi

Jonathan Chou

Bo Young Chun

Janet Cohan

Louise Collins

Lisa Cowan

Greta Covino

Deborah Cronin-Waelde

Linda Dagi

Reza Dana

Mindy Davis

Suzanne Day

Sandy DeCelle

Peter Delisle

April Dobbs

Claes Dohlman

Erica Donadio

Anne Marie Donnelly

Marlene Durand

Dean Eliott

Tobias Elze

Kimberly Farwell

Tanya Fedyshyn

Joan Feltman

Ashley Femino

John Fernandez

Ruben Fernandez

Cherie Florio

Jenna Forgione

Leila Foster

Martha Fraser

Suzanne Freitag

Sandra Gallagher

Matthew Gardiner

Elizabeth Garlo

Sharyn Ghiloni

Amanda Goggin

Evangelos Gragoudas

Scott Greenstein

Kathryn Hatch

Leo Hill

Fariba Houman

David Hunter

Deeba Husain

Mary-Lou Jackson

Maryann Jerrier

Yan Jiang

Grace Jonak

Ula Jurkunas

Justin Kanoff

Melanie Kazlas

Diane Keogh

Ivana Kim

Leo Kim

Carolyn Kloek

Magdalena Krzystolik

Anne Marie Lane

Mary Leach

Eliza-Eve Leas

Daniel Lefebvre

Kathleen Lennon

Olga Levy

Patricia Li

Michael Lin

Ann-Marie Lobo

John Loewenstein

Peter Lok

Alice Lorch

Migdali Lorenzo

Cara Ludwick

Pedro Lugo

Katie Luo

Christina Marko

Joe Marshall

Maureen Martinez

Kathy McCormack

Fran McDonald

Lisa McLellan

Samir Melki

Joan Miller

John Miller

Alfred Minincleri

Nicolas Moretti

Scot Morrison

Anne Murphy

Michael Navetta

Sheelagh Nelis-Swain

Toni Nuzzo

Bob O’Hare

Sheila O’Keefe

George Papaliodis

Louis Pasquale

Eric Pierce

Roberto Pineda

Corinne Powers

Suzette Profio

Andrew Rabkin

Michael Reinhart

Mike Ricci

Debbie Rich

Joseph Rizzo

Marsha Robinson

Alexandra Rondan

Debra Rogers

Barbara Ruchie

Charles Ruberto

Mary Savell

Samuel Scott

Barbara Scully

Alexandra Selivanova

Lucia Sobrin

Brian Song

Ravichandran Srinivasan

Jennifer Street

Christopher Taylor

Helen Todisco

Debra Trocchi

Angela Turalba

Edem Tsikata

Joseph Vadakekalam

Peter Veldman

Christina Venditti

Merideth Vida

Kenny Vien

Rhonda Walcott-Harris

Jay Wang

Suzanne Ward

Amy Watts

Lauren Winter

Julia Wong

Emily Woodcock

Janet Yedziniak

Lucy Young

Research Fellow:

Jing Zhang, M.D.

Study Coordinators:

Laura D’Amico

Madeline Freeman

Medical illustrations by:

Laurel Cook Lhowe

Graphic Design by:

Marc Harpin, Rhumba

48

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617-523-7900

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

MassEyeAndEar.org

Documents

our latest volume of Quality and Outcomes (Ophthalmology)