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QUALITY
AND
OUTCOMES
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 postoperative 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 Fernandez
Joan W. Miller, MD
President and CEO
Henry Willard Williams Professor of Ophthalmology
Massachusetts Eye and Ear
Chief and Chair, Department of Ophthalmology
Massachusetts Eye and Ear
Massachusetts General Hospital
Harvard Medical School
1
About the Quality and Outcomes Program
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
2
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
Massachusetts Eye and Ear
Harvard Medical School
Simon 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.
2
Englander 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.
1
3
Ophthalmology Clinical Leadership in Quality: 2015
Joan W. Miller, M.D.
Henry Willard Williams Professor and Chair of Ophthalmology,
Harvard Medical School
Chief of Ophthalmology, Massachusetts Eye and Ear,
Massachusetts General Hospital
Teresa C. Chen, M.D.
Associate Professor of Ophthalmology, Harvard Medical School
Chief Quality Officer, Department of Ophthalmology,
Massachusetts Eye and Ear
Matthew Gardiner, M.D.
Assistant Professor of Ophthalmology, Harvard Medical School
Associate 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 Ophthalmology
Massachusetts Eye and Ear
Deborah Cronin-Waelde, RN, MSN, NEA-BC
Director of Operations, Ophthalmology
Massachusetts Eye and Ear
Sunil Eappen, M.D.
Assistant Professor of Anaesthesia, Harvard Medical School
Chief Medical Officer, Chief of Anesthesiology,
Massachusetts Eye and Ear
4
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
Clinical Locations
Boston — Main Campus
Boston — Longwood
Boston —
­ Joslin
Braintree
Concord
leaders. Our world-renowned experts are continuously innovating in the fields of
Duxbury
translational and bench research, turning insights into cures that benefit countless
East Bridgewater
people. We continue to forge new partnerships and alliances—locally, nationally
and beyond our borders—to increase our reach and make our expertise, services
Medford
and resources available to all who need them.
Milton
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.
Newton
Plainville
Providence
Quincy
Stoneham
Waltham
2014 Hospital Statistics
Weymouth
(Jan 1 – Dec 31, 2014)
For more information, visit
Patient Volume
MassEyeAndEar.org/Locations.
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
Massachusetts Eye and Ear
Ophthalmology Department
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
Academic Affiliations
Harvard Medical School
training in the areas of cornea, retina and glaucoma, and have pioneered tools and
Massachusetts General Hospital
treatments for numerous diseases and conditions ranging from retinal detachment
Brigham and Women’s Hospital
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.
Joslin Diabetes Center/
Beetham Eye Institute
Boston Children’s Hospital
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:
Beth Israel Deaconess
Medical Center
Veterans Affairs Boston
Healthcare System
VA Maine Healthcare System
Cambridge Health Alliance
Aravind Eye Hospital, India
Ocular Genomics Institute
Ocular Regenerative Medicine Institute
Infectious Disease Institute
Eye and ENT Hospital
of Fudan University,
Shanghai, China
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 NeuroOphthalmology and Burn Unit consultations at MGH.
• Mass. Eye and Ear staff screen MGH patients with or at high risk for diabetic
eye disease on a same-day basis in the main campus Retina Service and
through MGH’s Chelsea HealthCare Center teleretinal screening program.
6
• 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.
For more information about
the Mass. Eye and Ear Quality
Program or the Department
of Ophthalmology, please
visit our website at
www.MassEyeAndEar.org.
• 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-theart 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.
Eye Anatomy
sclera
retina
Data reported for 2010,
2011, 2012, 2013 and 2014
represent calendar years.
The 2009 data represent
iris
macula
pupil
vitreous
cornea
optic nerve
lens
8
12-month results as noted.
• 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.
Key Statistics: Mass. Eye and Ear Ophthalmology
January 1 – December 31, 2014
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
9
Emergency Department:
Ophthalmology Emergency Visits
1,500
This bar graph shows the
number of ophthalmology
patients seen monthly by the
1,200
Department during the past
900
six calendar years. Throughout
this time, the Emergency
600
Department maintained a
high volume of ophthalmic
emergency visits, with an
300
average of 1,060 patients per
month in 2009, 1,050 in 2010,
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2009
(N = 12,717)
2010
(N = 12,603)
2011
(N = 13,086)
1,091 in 2011, 1,146 in 2012,
1,142 in 2013 and 1,189 in
Month
2014. Patient volume generally
2012
(N = 13,757)
2013
(N = 13,709)
2014
(N = 14,270)
increases in the summer.
Emergency Department:
Ophthalmology Visit Times
5
National Average 4.12 Hours
4
Massachusetts Average 4.06 Hours
3.0
3
3.1
2.7
Hours
Number of visits
Mass. Eye and Ear Emergency
2.3
2.1
2.3
2
1
0
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
10
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 finished 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.
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:
Distribution of Ophthalmology Diagnoses
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)
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.
0
200
400
600
800
1,000
Number of diagnoses
Emergency Department:
Ophthalmology “Left Without Being Seen” (LWBS) Rate
10
9
8
Percentage
7
6
5
1.7% to 4.4% 1-3
4
3
2
1.3%
1.2%
1
1.0%
0
2012 (N = 13,757)
“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
The Mass. Eye and Ear
Emergency Department
has a lower LWBS rate
when compared to national
benchmarks.
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.
2013 (N = 13,709)
2014 (N = 14,270)
National Benchmark 11
Eye Trauma Surgery:
Time to Surgical Repair for Open-Globe Injuries
99.2
Percentage
80
100.0
99.2
100
76.3
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.
78.8
69.7
60
40
20
0
< 12 hours
< 24 hours
Time to Operating Room
2012
2013
2014
Eye Trauma Surgery:
Postoperative Median Vision
20/20
20/25
20/30
20/40
20/40
Best-Corrected Visual Acuity
20/50
20/60
20/60
20/70
20/70
20/80
20/100
20/100
20/100
20/200
20/400
Count
Fingers
Count
Fingers
Hand
Motion
Hand
Motion
Hand
Motion
Hand
Motion
2013
(N = 68)
2014
(N = 74)
Light
Perception
Light
Perception
No Light
Perception
2010
(N = 58)
2011
(N = 59)
Preoperative Vision
Postoperative Vision
12
2012
(N = 63)
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.
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:
Rates of Endophthalmitis After Open-Globe Repair
Percentage of endophthalmitis
25
20
15
10
5
0
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
2.6% to 17%
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 postoperative day 4, he had increased inflammation, which was
U.S. Rate 6.9%
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
1.7%
inflammation, pain, and decreased vision. Vitreous culture
0% 0% 0% 0% 0%
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.
2009 (N = 95)
The other case of endophthalmitis was a 34-year-old
2010 (N = 96)
male with a Zone II injury from a metal shim. One day after
2011 (N = 98)
repair of a 1mm scleral wound that was 4 mm posterior to the
2012 (N = 122)
limbus, the patient had 20/25 vision but also had extensive
2013 (N = 118)
anterior chamber and fibrin reaction, which was concerning for
2014 (N = 118)
endophthalmitis. He was treated with intravitreal antibiotics;
International Benchmark
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
Endophthalmitis rates after
eye trauma surgery performed
at Mass. Eye and Ear are the
lowest rates reported in the
country. Based on the Mass.
Eye and Ear experience and
the low percentage of cases
with endophthalmitis, we
recommend that institutions
adopt a standardized protocol
for treating open-globe
injuries and consider the
use of prophylactic systemic
antibiotics.1
Reference: 1Andreoli CM, 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.
The photo on the left illustrates
the right eye of a patient who
Eye Trauma Surgery
Photo courtesy of
Matthew Gardiner, M.D.
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.
13
Cataract Surgery
The Comprehensive
Ophthalmology and Cataract
Consultation Service at
Mass. Eye and Ear provides
a full spectrum of integrated
patient care, including annual
and diabetic eye exams,
prescriptions for eyeglasses,
normal lens
continued management of
cataract
or cloudy
lens
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.
Cataract Surgery:
Achieving Target Refraction (Spherical Equivalent)
71% to 94%1-4
100
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.
Percentage within range of target refraction
90
80
70
60
50
40
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
30
20
10
0
< -2
-2 to < -1
-1 to +1
> +1 to +2
Dioptric difference from target refraction
2009 (N = 974)*
2010 (N = 1,285)
2011 (N = 1,250)
2012 (N = 1,437)
2013 (N = 1,664)
2014 (N = 1,829)
International Benchmark
*July 2008-June 2009
14
> +2
References: 1Kugelberg M, Lundström M.
Factors related to the degree of success
in achieving target refraction in cataract
surgery: Swedish National Cataract
Register study. J Cataract and Refract
Surg 2008;34(11): 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.
4
Simon 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.
Consultation Service has
consistently met or exceeded
international benchmarks for
successful cataract surgery.
Cataract Surgery:
Intraoperative Complication Rates
10
The Mass. Eye and Ear
Comprehensive Ophthalmology
Percentage of intraoperative complications
9
Service has some of the lowest
8
intraoperative complication
7
rates compared to international
benchmarks.
6
0.3% to 4.4%
5
4
3
2
1
0
0% to 0.9%
0% to 1.7%
1.7% 1.6%
0.3% 0.2% 0.3%
0.2% 0.3% 0.05%
Descemet tear
2012 (N = 1,464)
0.1% to 1.2%
1.0%
PC tear and/or
vitreous loss
2013 (N = 1,719)
Dropped lens/retained
lens fragment
2014 (N = 1,927)
0.2%
0.5% 0.3%
Zonular dialysis
International Benchmark
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.
15
Retina Surgery:
Retinal Detachment and Retinal Detachment Repair
scleral buckle
The Retina Service at Mass.
Eye and Ear is one of the
vitreous
detachment
largest subspecialty groups
of its kind in the country. Our
clinicians are highly skilled at
diagnosing and treating a full
range of ocular conditions,
subretinal
fluid
retinal
detachment
retinal
tear
including macular degeneration,
diabetic retinopathy, retinal
detachments, ocular tumors,
intraocular infections, and
severe ocular injuries.
Retina Surgery:
Single Surgery Success Rate for
Primary Rhegmatogenous Retinal Detachment
59.4% to 95%1-5
100
90
80.0%
Percentage of retinas attached
80
76.4%
79.2%
70
60
50
40
30
20
10
0
2012 (N = 173)
2013 (N = 220)
2014 (N = 221)
International Benchmark
16
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.
4
Sodhi 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):5067. 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.
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
Retina Surgery:
Final Retinal Reattachment Rate for
Primary Rhegmatogenous Retinal Detachment
97% to 100%1-5
100
95.6%
97.4%
98.4%
99.4%
99.5% 100.0%
90
Percentage of retinas reattached
80
70
60
50
40
30
20
10
0
2009 (N = 160)*
2010 (N = 78)
2011 (N = 189)
2012 (N = 173)
2013 (N = 220)
2014 (N = 221)
International Benchmark
*March 2008-February 2009
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 frequencydoubled 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.
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
Macular Hole Surgery:
Single Surgery Success Rate at Three Months
89.8% to 93%1-3
100
Percentage of closed macular holes
90
93.1% 93.9% 91.7%
80
70
60
50
40
30
20
10
0
2012 (N = 29)
2013 (N = 33)
2014 (N = 24)
National Benchmark
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 facedown and seated position after idiopathic macular hole surgery: a randomized clinical trial.
Am J Ophthamol 2008; 146(1): 128-134.
17
Retina Surgery:
Rates of Endophthalmitis After Intravitreal Injection
10
9
Percentage of endophthalmitis
8
7
6
5
4
3
2
1
0
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
0.02% to 1.9%1
six months follow-up after treatment,
best corrected visual acuity returned to
the patient’s baseline vision of
0.00% 0.05% 0.00% 0.03% 0.00% 0.02%
“counting fingers” (CF). In the second
case, the patient presented with a
hypopyon and vitreous debris five days
2009 (N = 1,989)
2010 (N = 2,190)
after the injection. Anterior chamber
2011 (N = 3,319)
2012 (N = 6,094)
and vitreous taps were performed with
2013 (N = 7,458)
2014 (N = 8,853)
injections of antibiotics. The vitreous
International Benchmark
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.
Retina Surgery
(left) Photograph of
endophthalmitis
Photo courtesy of Lucy H. Young,
M.D., Ph.D., F.A.C.S.
Retina Surgery:
Ocular Melanoma Center –
Globe Perforation Rate from Surgery
10
9
Percentage of globe perforations
8
7
6
5
4
3
2
1
0
0%
0%
2012 (N = 99)
2013 (N = 101)
0%
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.
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.
2014 (N = 105)
19
Glaucoma Surgery
Glaucoma is a group of
disorders that affect the optic
nerve, which transmits image
signals from the retina to the
brain. In glaucoma, damage to
the optic nerve results in vision
PRESSURE
loss. The main risk factor for
glaucoma is elevated pressure
in the eye. Members of the
Mass. Eye and Ear Glaucoma
Consultation Service are trained
in the most advanced laser
and surgical procedures to
treat glaucoma. Our specialists
treat patients with all forms
and stages of glaucoma—even
those with advanced disease—
Glaucoma Surgery:
Trabeculectomy and Tube Shunt Infection Rates
25
Percentage of infections
20
15
10
0.12% to 8.33% 1
5
0%
0
0%
0%
0%
2010 (N = 245)
2011 (N = 270)
2012 (N = 323)
2013 (N = 307)
2014 (N = 316)
International Benchmark 0%
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.
20
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.
Trabeculectomy and Glaucoma Implant Surgery:
Intraoperative Complications
Percentage of intraoperative complications
10
The Mass. Eye and Ear
Glaucoma Consultation Service
1% to 8%
8
continues to maintain among
the lowest intraoperative
complication rates compared to
6
international benchmarks.
4
1.1% to 3%
0% to 3%
2
1%
0.7%
0.2% to 1%
0% to 1%
0
Conjunctival
tear/buttonhole
Hyphema
Scleral flap
trauma
Vitreous loss/
prolapse
Suprachoroidal
hemorrhage
Scleral
perforation
2007-2009 (N = 308)* 2010 (N = 245) 2011 (N = 270) 2013 (N = 217)
2014 (N = 215) International Benchmark Aqueous
misdirection
2012 (N = 323)
*July 2007-June 2009
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:
International benchmarks:1-5
Conjunctival tear/buttonhole: 0.5%
Conjunctival tear/buttonhole: 1.1%-3.0%
Hyphema: 0%
Hyphema: 1.0%-8.0%
Scleral flap trauma: 0.5%
Scleral flap trauma: 0.7%
Vitreous loss (vitreous prolapse): 0%
Vitreous loss (vitreous prolapse): 1.0%
Suprachoroidal hemorrhage: 0%
Suprachoroidal hemorrhage: 0%-1.0%
Scleral perforation: 0%
Scleral perforation: 0%-3.0%
Aqueous misdirection: 0.5%
Aqueous misdirection: 0.2%-1.0%
The 215 cases evaluated included:
65 trabeculectomies without scarring
15 trabeculectomies with previous scarring
118 primary tube surgeries
17 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.
21
Glaucoma Surgery:
Mitomycin C Trabeculectomy Reoperation Rates
at One Month and Six Months
10
9
Percentage of reoperation
8
7
5.8%
6
5
4.3%
4
3
2.2%
2
1
0%
0
One Month
Postoperative
(N = 93) (N = 74)
2013
22
Six Months
Postoperative
(N = 92) (N = 69)
2014
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.
In summary, the Mass.
Eye and Ear Glaucoma
Consultation Service
achieves low trabeculectomy
reoperation rates.
Glaucoma Laser Surgery:
Intraocular Pressure (IOP) Spikes
40
Preoperative and postoperative
0% to 35%
intraocular pressure (IOP)
Percentage of IOP spikes
0% to 31.7%
measurements were taken
30
using the Tono-Pen (Reichert,
Buffalo, NY) prior to the laser
7% to 10.3%
20
procedure and within one
hour of the conclusion of
5.7% to 13%
0% to 9.8%
10
0%
0.02% to 4%
the laser procedure. For this
analysis, if multiple pressure
3%
readings were taken, the
0
average pressure reading was
Laser Peripheral
Iridotomy
Capsulotomy
Laser
Trabeculoplasty
(ALT/SLT)
Overall
Laser Peripheral
Iridotomy
Laser
Trabeculoplasty
(ALT/SLT)
Overall
2013 (N = 587)
2014 (N = 591)
used when calculating the
IOP difference (postoperative
≥10 mm Hg
≥5 mm Hg
2012 (N = 556)
Capsulotomy
minus preoperative). All
measurements were taken by a
International Benchmark
certified ophthalmic technician.
All patients received either
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
Laser peripheral iridotomy:
Mass. Eye
and Ear
International1-8
0.5% before the laser procedure
and prednisolone 1% after
the procedure.
≥10 mm Hg
Mass. Eye
and Ear
International1,3-4,6-9
24.0%
0% to 35%
4.7%
0%
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%
Capsulotomy:
brimonidine or apraclonidine
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.
8
Chen 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 hydrochloride on acute intraocular pressure rise after argon laser iridotomy. Korean J Ophthalmol 1991; 5(1): 37-41.
23
Refractive Surgery (Laser Vision Correction)
1.
Refractive surgery, commonly
2.
known as laser vision
correction, is a term given
to surgical procedures
designed to correct certain
visual problems such as
myopia (nearsightedness),
3.
hyperopia (farsightedness),
4.
and astigmatism. The Mass.
Eye and Ear Cornea and
Refractive Surgery Service
offers a number of refractive
procedures, the most common
of which are laser-assisted
in situ keratomileusis
(LASIK) and photorefractive
keratectomy (PRK).
Refractive Surgery — LASIK for Myopia:
Achieving Target Refraction (Spherical Equivalent)
Percentage within 0.5 diopters of target refraction
90.1% 89.1%
86.9% 86.9% 88.1% 89.3%
90
80
70
60
50
40
30
20
10
0
2009 (N = 289)*
2010 (N = 252)
2011 (N = 260)
2012 (N = 271)
2013 (N = 212)
2014 (N = 165)
International Benchmark
*July 2008-June 2009
24
that had LASIK surgery had
sufficient follow-up data for
analysis. Sufficient follow-
70% to 83%1-2
100
During the 2014 calendar
year, 197 of the 250 eyes
up was defined as at least
During the 2014 calendar year, 165 of
the 214 eyes that had LASIK surgery were
myopic and had at least one month followup 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.
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).
Refractive Surgery — LASIK for Different Degrees of Myopia:
Achieving Target Refraction (Spherical Equivalent)
100
Percentage within 0.5 diopters of target refraction
90
97.3
91.5
90.4
The Mass. Eye and Ear Cornea
96.8
95.0
91.1
86.1
87.8
91.2
85.4
and Refractive Surgery Service
87.9 89.2
82.1
80
81.3 81.3
81.3 80.0
75.9
continues to maintain a high
overall success rate for LASIK
surgery for myopia.
70
60
50
40
30
20
10
0
Low Myopia
less than 3 diopters of sphere
2009 (N = 289)*
2012 (N = 271)
Moderate Myopia
3 to <7 diopters of sphere
2010 (N = 252) 2011 (N = 260)
2013 (N = 212)
2014 (N = 165)
High Myopia
7 to 10 diopters of sphere
*July 2008-June 2009
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.
25
Refractive Surgery — LASIK for Hyperopia:
Achieving Target Refraction (Spherical Equivalent)
66.7% to 91%1-3
Percentage within 0.5 diopters of target refraction
100
90
85.0%
79.3%
80
77.8%
80.6%
78.1%
68.0%
70
60
50
40
30
10
0
2010 (N = 29)
2011 (N = 25)
2012 (N = 36)
2013 (N = 36)
2014 (N = 32)
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.
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. 20
2009 (N = 40)*
Of the 36 eyes that had LASIK surgery for
hyperopia during the 2014 calendar year,
32 had three months or more of followup 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
International Benchmark
*July 2008-June 2009
Refractive Surgery — LASIK:
Enhancement/Retreatment Rates at Six Months Follow-up
50
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
45
LASIK retreatments/enhancements
40
35
3.8% to 29.4% 1-3
30
25
20
15
10
7.4%
5
2.7%
6.8%
5.2%
6.1%
0
26
2010 (N = 296) 2011 (N = 285)
2012 (N = 307) 2013 (N = 248)
2014 (N = 197) International Benchmark 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.
For the past five years, the
Mass. Eye and Ear Cornea and
Refractive Surgery Service has
maintained low enhancement/
retreatment rates when
compared to international
benchmarks.
Cornea Surgery:
Keratoprosthesis (KPro)
(left) Photograph of
keratoprosthesis (KPro)
Photo courtesy of
Claes Dohlman, M.D., Ph.D.
Keratoprosthesis Surgery:
Surgical Indications
Hypotony and
Corneal Edema
5.9%
Failed Graft
52.9%
Aniridic
Keratopathy
11.8%
Corneal
Neovascularization
and Scarring
29.4%
N = 17
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 StevensJohnson syndrome, and in another eye
due to herpes zoster.
Reference: 1Ament JD, Stryjewski TP, Ciolino
JB, Todani A, Chodosh J, Dohlman CH. Costeffectiveness of the Boston Keratoprosthesis. Am J
Ophthalmol 2010; 149(2): 221-228.
The Boston Keratoprosthesis
(KPro) is an artificial cornea
developed at Mass. Eye and Ear
by Claes Dohlman, M.D., Ph.D.
and colleagues. Dr. Dohlman is
former Chief 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 commonly 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
27
Keratoprosthesis Surgery:
Visual Outcomes
56% to 89%1-3
100
90
84%
76%
80
66.7%
70
Percentage
76.5%
60
50
40
30
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.
20
10
0
20/200 or better
2011 (N = 27) 2012 (N = 25)
2013 (N = 29)
2014 (N = 17)
National Benchmark
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.
Keratoprosthesis Surgery:
Retention Rates
90.5% to 95%1-2
100%
100%
100%
100%
100
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
90
80
Percentage
70
60
50
40
30
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.
20
10
0
2011 (N = 27) 2012 (N = 25)
2013 (N = 29)
2014 (N = 17)
National Benchmark
28
Cornea Surgery:
Penetrating Keratoplasty
(left) The photos illustrate
the before and after of an
eye that underwent
penetrating keratoplasty (PK)
for pseudomonas keratitis
in a prior radial keratotomy
incision.
Photo courtesy of
James Chodosh, M.D., M.P.H.
Cornea Surgery:
Distribution of Full-Thickness and
Partial-Thickness Keratoplasty
Descemet’s
Stripping Endothelial
Keratoplasty (DSEK)
54.9%
Descemet’s Membrane
Endothelial Keratoplasty
(DMEK)
7.3%
Deep Anterior
Lamellar Keratoplasty
(DALK)
8.3%
Penetrating
Keratoplasty (PK)
29.5
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).
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.
N = 193
29
Cornea Surgery:
Surgical Indications for Penetrating Keratoplasty (PK)
Bullous
Keratopathy
3.6%
Corneal Edema
3.6%
Corneal Dystrophy
3.6%
Failed
Corneal
Graft
54.5%
Corneal Scar
14.5%
Keratoconus
20.0%
N = 55
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.
Corneal transplant surgery
provides clear cornea tissue
from a donor to replace
diseased host tissue.
Cornea Surgery:
Clear Corneal Grafts after Penetrating Keratoplasty (PK)
Surgery at Three Months Follow-up
92.5% to 95%1-2
96.8%
Percentage of grafts clear for elective PK
100
93.0% 92.8%
98.3% 98.3%
90
80
70
60
50
40
30
20
10
0
2009 (N = 126)*
2010 (N = 71)
2011 (N = 69)
2012 (N = 60)
2013 (N = 58)
2014 (N = 55)
International Benchmark
30
*July 2008-July 2009
92.7%
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.
Mass. Eye and Ear PK surgery
success rates continue to
meet or exceed international
benchmarks.1-2
Oculoplastic Surgery:
Dacryocystorhinostomy (DCR) Lacrimal Bypass Surgery
Dacryocystorhinostomy (DCR)
is a surgery that aims to
Lacrimal gland
improve tear drainage from the
Canaliculus
lacrimal sac to the nose.
Lacrimal sac
DCR ostium site
Nasolacrimal duct
Oculoplastic Surgery:
Reoperation Rate for External Dacryocystorhinostomy
(Ex-DCR) Surgery at Six Months Follow-up
Reoperation rate after external DCR surgery (%)
25
20
15
7.8% to 12.5%1-3
10
5
1.8%
0
0.0%
0.0%
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
For the past three years, the
Mass. Eye and Ear Ophthalmic
Plastic Surgery Service has
maintained a low reoperation
rate for Ex-DCR surgeries
compared to international
benchmarks.
2012 (N = 70)
2013 (N = 56)
2014 (N = 54)
International Benchmark
References: 1Dolman PJ. Comparison of external dacryocystorhinostomy with
nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003; 110: 78-84.
2
Karim 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.
31
Oculoplastic Surgery:
Reoperation Rate for Endoscopic Dacryocystorhinostomy
(En-DCR) Surgery at Six Months Follow-up
Reoperation rate after endoscopic DCR surgery (%)
25
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
20
15
2% to 11%1-4
10
7.1%
5.6%
5
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: 15751582. 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.
0
2013 (N = 18)
2014 (N = 28)
International Benchmark
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.
Oculoplastic Surgery:
Reoperation Rate for Lid Surgeries at Six Months Follow-up
Reoperation rate after lid surgery (%)
25
20
15
2.6% to 8.7%1-2
10
5
2.9% 2.6%
3.1% 2.8%
1.7%
0
2009 (N = 343)*
2010 data are not available
at the time of this publication
2011 (N = 416)
2012 (N = 467)
2013 (N = 574)
2014 (N = 540)
International Benchmark
32
*March 2008-February 2009
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.
The Mass. Eye and Ear
Ophthalmic Plastic Surgery
Service continues to have one
of the lowest reoperation rates
for eyelid surgeries compared
to international benchmarks.
Pediatric and Adult Strabismus Surgery
esotropia (ET)
exotropia (XT)
Recession and resection
procedures are most commonly
performed for horizontal
misalignment. Other surgeries
less frequently performed
include loop myopexies and
transpositions.
resection surgery
muscle
advanced
recession surgery
muscle
recessed
part of muscle
resected
after surgery
Pediatric and Adult Strabismus Surgery:
Outcomes Criteria
Strabismus surgery, the most commonly performed ophthalmic procedure in children,
is offered to adults as well. Surgery is performed for a variety of indications, including
restoration of binocular vision, restitution of normal eye contact (reconstructive),
treatment of double vision, or reduction of anomalous head posture (torticollis).
Since the desired surgical outcome depends on the primary indication of surgery, we
developed a unique goal-directed methodology to assess surgical outcomes.1 This
approach provides the most clinically relevant appraisal of our outcomes. The model
excludes no patient based on diagnosis or procedure performed, and therefore facilitates
stratification based on the presence or absence of risk factors (ophthalmic or systemic)
that might impact results. The tables on the following pages summarize the criteria,
and the figures that follow illustrate our outcomes using this goal-directed methodology.
These reported pediatric and adult strabismus surgery outcomes include procedures
done at all surgical locations.
Our goal-directed methodology
provides a clinically relevant
appraisal of strabismus surgery
outcomes. Reported results
were monitored two to six
months after strabismus
surgery was performed.
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.
33
Pediatric and Adult Strabismus Surgery:
Outcomes Criteria
1. Goal—Binocular Potential for Esotropia (ET)
Subjective
Distance angle1 Indications for strabismus
Near angle
Excellent
ET≤10∆ or XT≤5∆
No XT, any ET
Good
10∆< ET≤15∆ or
5∆< XT≤10∆
X(T)≤10∆ any ET
Poor
Recommend re-operation (horizontal)
ET>15 or XT>10
Near angle
Excellent
Near stereo-acuity <2 octaves
worsened from pre-op and
not diminished to nil2
XT<10∆XT<10∆
or ET<6∆
or ET<6∆
Good
Near stereo-acuity <2 octaves
worsened from pre-op and
not diminished to nil2
10∆≤XT<15∆
or 6≤ET≤10∆
10≤XT<15∆
or 6≤ET≤10∆
Recommend re-operation
(horizontal)
XT>
_15∆
or ET>
>10∆
XT>
_15∆
or ET>
>10∆
1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky
2. Accept Worth-4-dot test (W4D) fusion if stereo-acuity data not available
∆ = prism diopter
3. Goal—Reconstructive (ET or XT)
Subjective
Angle1,2
Excellent3
ET or XT≤10∆
Good
10∆<ET or XT≤15∆
Poor
Recommend re-operation
(horizontal)
ET or XT>15∆
1. O
rder of preference for angle used: Krimsky > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT)
2. Near angle (unless stated goal of distance angle)
3. Ignore coexisting vertical deviation
34
(reconstructive), treatment of
(torticollis).
∆ = prism diopter
Poor
of normal eye contact
of anomalous head posture
1. Order of preference for angle used: > simultaneous prism-and-cover test (SPCT) > alternate prism-and-cover test (APCT) > Krimsky
of binocular vision, restitution
double vision, or reduction
2. Goal—Binocular Potential for Exotropia (XT)
Sensory
Distance angle1
surgery included restoration
Pediatric and Adult Strabismus Surgery:
Outcomes Criteria
4. Goal—Resolution of Diplopia (ET or XT)
Subjective
Excellent
No diplopia in primary1
Good2,3
Diplopia controlled with prism
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
PoorRecommend re-operation for diplopia and/or diplopia
not comfortably controlled with prism correction
number of torticollis surgeries
was small compared to the
other objectives, and thus
1. At distance and near but may have rare diplopia in primary, or diplopia away from primary
2. Preexisting vertical alignment controlled with prism does not affect result if no increase
3. New vertical alignment requiring prism cannot exceed “good” outcome
precluded analysis.
5. Goal—Reduction of Torticollis (ET or XT)
Subjective1Torticollis2
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)
35
Pediatric and Adult Strabismus Surgery:
Exotropia Outcomes Stratified by Goal
100
12.5
5.7
5.7
13.1
14.3
3.3
80
16.1
18.4
13.3
9.4
18.8
13.2
14.6
20.4
Percentage
13.9
31.2
8.9
21.9
100
patients had surgery to restore
100
87.5
40
88.6
83.6
72.4
71.5
61.2
77.4
72.3
binocular vision, 70 for
reconstructive purposes, 3 to
54.8
46.9
20
underwent surgical remediation
of exotropia in 2014, 31
29.1
60
Of the 106 patients who
resolve diplopia, and 2 to
0
2012
(N = 16)
2013
(N = 8)
2014
(N = 3)
2012
(N = 98)
Diplopia
%Excellent
2013
(N = 61)
2014
(N = 70)
2012
(N = 49)
Reconstructive
%Good
%Poor
2013
(N = 32)
2014
(N = 31)
2012
2013
2014
(N = 165) (N = 101) (N = 106)
Binocular Potential
resolved uncomplicated
torticollis. Exotropia patients
are grouped according to the
Overall
*N includes surgeries performed to resolve uncomplicated torticollis (not included in analysis)
primary goal for surgery.
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.
Pediatric and Adult Strabismus Surgery:
Exotropia Outcomes Stratified by Risk Factors
100
4.0
4.0
33.3
Percentage
80
6.9
19.4
9.7
4.9
13.0
30.0
2.8
25.0
100
100
100
93.1
92
77.8
66.7
25.0
14.0
16.7
11.8
9.8
60.9
70.6
78.4
%Excellent
%Good
%Poor
Binocular Potential
2 had surgery to resolve
Overall
*N includes surgeries performed to resolve uncomplicated torticollis (not included in analysis)
This figure presents outcomes for exotropia surgery in patients with or without associated risk
factors. Risk factors included the following: bilateral vision limitation (e.g., albinism), conditions
resulting in hyper- or hypotonia, craniosynostosis or craniofacial anomalies, 3rd nerve palsy, 4th
nerve palsy, prior strabismus surgery, Duane syndrome, prior surgery for retinal detachment, Graves’
orbitopathy, antecedent orbital trauma with or without orbital fracture, congenital fibrosis of the
extraocular muscles and simultaneous surgery for nystagmus or vertical strabismus.
36
risk factors. Of the 55 patients
with no associated risk factors,
37.5
2013
2013
2014
2014
2013
2013
2014
2014
2013
2013
2014
2014
2013
2013
2014
2014
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors
(N = 5) (N = 3) (N = 1) (N = 2) (N = 25) (N = 36) (N = 29) (N = 41) (N = 20) (N = 12) (N = 23) (N = 8) (N = 50) (N = 51) (N = 55) (N = 51)
Reconstructive
exotropia who underwent
51 patients had associated
76.3
0
Diplopia
Of the 106 patients with
strabismus surgery in 2014,
37.5
74.0
50.0
16.4
5.9
85.4
45.0
20
7.3
23.5
12.0
26.1
60
40
33.3
uncomplicated torticollis.
Pediatric and Adult Strabismus Surgery:
Esotropia Outcomes Stratified by Goal
100
7.7
18.2
7.1
Percentage
80
12.5
11.7
9.7
7.8
4.6
4.7
13.3
14.5
10.7
15.2
10.1
10.9
13.4
12.2
8.8
7.6
9.4
6.3
restore binocular vision, 43 for
92.9
92.3
81.8
90.7
77.8
80.5
76
75.4
73.9
84.3
80.2
77.8
reconstructive goals, 28 to
resolve diplopia, and 10 to
20
0
who had strabismus surgery in
2014, 46 underwent surgery to
60
40
Of 127 patients with esotropia
resolve torticollis.
2012
(N = 22)
2013
(N = 26)
2014
(N = 28)
2012
(N = 9872
Diplopia
%Excellent
2013
(N = 77)
2014
(N = 43)
2012
(N = 75)
Reconstructive
%Good
%Poor
2013
(N = 69)
2014
(N = 46)
2012
2013
2014
(N = 171) (N = 172) (N = 127)
Binocular Potential
Overall
*N includes surgeries performed to resolve uncomplicated torticollis (not included in analysis)
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.
Pediatric and Adult Strabismus Surgery:
Esotropia Outcomes Stratified by Risk Factors
100
8.7
12.5
Percentage
80
10.4
12.5
10.3
6.3
5.9
7.7
3.9
12.9
20.0
9.3
13.3
10.8
20.0
2.9
36.4
8.6
13.9
6.3
11.1
7.8
4.8
7.8
100
87.5
100
91.3
94.1
79.3
81.2
esotropia who underwent
strabismus surgery in 2014,
60
40
Of the 127 patients with
64 patients had associated risk
88.4
77.8
66.7
80.6
77.1
79.8
84.1
84.4
63.6
factors. Of 10 surgeries
performed to resolve torticollis,
20
4 had associated risk factors.
0
2013
2013
2014
2014
2013
2013
2014
2014
2013
2013
2014
2014
2013
2013
2014
2014
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
No Risk
Risk
Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors Factors
(N = 10) (N = 16) (N = 5) (N = 23) (N = 29) (N = 48) (N = 17) (N = 26) (N = 54) (N = 15) (N = 35) (N = 11) (N = 93) (N = 79) (N = 63) (N = 64)
Diplopia
%Excellent
Reconstructive
%Good
%Poor
Binocular Potential
Overall
*N includes surgeries performed to resolve uncomplicated torticollis (not included in analysis)
This figure presents outcomes for esotropia surgery in patients with or without associated risk
factors. Risk factors included the following: prior strabismus surgery, bilateral vision limitation (e.g.,
albinism), systemic conditions resulting in hyper- or hypotonia, craniosynostosis or craniofacial
anomalies, Graves’ orbitopathy, antecedent orbital trauma with or without orbital fracture, prior
surgery for retinal detachment, heavy eye syndrome, Brown syndrome, Duane syndrome, 6th nerve
palsy, preoperative esotropia ≥ 50 prism diopters, congenital fibrosis of the extraocular muscles,
and simultaneous surgery for nystagmus or vertical strabismus.
37
Pediatric and Adult Strabismus Surgery:
Scleral Perforation During Strabismus Surgery
Rate of Scleral Perforation (%)
5.00
4.00
3.00
0.08% to 1.5%1-3
2.00
1.00
0.54%
0.00%
0.00
2013 (N = 367)
2014 (N = 578)
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.
Of the 578 strabismus
procedures performed, there
were no scleral perforations.
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.
Pediatric and Adult Strabismus Surgery:
Infection Within 30 days After Surgery
Postoperative infection rate (%)
5.00
4.00
0.04% to 2.6%5-7
3.00
0.05-0.09%1-4
2.00
0.9%
1.00
0.00
0.04%8
0.17% 0.0% 0.0%
0.0% 0.0%
2013
2014
(N = 350) (N = 578)
2013
2014
(N = 83) (N = 70)
2013
2014
(N = 40) (N = 40)
Strabismus
Surgery
Pediatric
Cataract
Surgery
Ptosis
Surgery
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.
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.
Neuro-Ophthalmology Service:
Demographics of Adult Strabismus Surgery Patients
During the 2014 calendar year, the Mass. Eye and Ear Neuro-Ophthalmology Service
The surgical volume of the
performed strabismus surgeries on 120 patients. The patients included 72 (60%) females
Mass. Eye and Ear Neuro-
and 48 (40%) males. Similar results were reported for calendar years 2012 and 2013,
Ophthalmology Service has
during which time there were 59 (53.6%) females and 51 (46.4%) males among a total
increased from calendar year
of 110 patients for calendar year 2013, and 57 (51.8%) females and 53 (48.2%) males
2012 to calendar year 2014.
among a total of 110 patients for calendar year 2012.
Male
48%
Female
52%
2012 (N = 110)
Male
46%
Female
54%
Male
40%
2013 (N = 110)
Female
60%
2014 (N = 120)
Neuro-Ophthalmology Service:
Preoperative Symptoms in Adult Strabismus
Surgery Patients
100
During the 2014 calendar year,
the Mass. Eye and Ear NeuroOphthalmology 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).
90
80
Percent of patients
70
60
50
40
30
Diplopia is one of the most
common indications for
surgical intervention at the
Mass. Eye and Ear NeuroOphthalmology Service.
20
10
0
2012
(N = 110)
2013
(N = 110)
2014
(N = 120)
Calendar Year
Without diplopia
With diplopia
39
Neuro-Ophthalmology Service:
Underlying Etiologies Associated
with Adult Strabismus Surgery
Skew deviation
0.8%
Congenital,
idiopathic, or
traumatic strabismus
61.7%
Cerebellar
degeneration
0.8%
Multiple cranial neuropathies
1.6%
Sixth nerve palsy
4.2%
Third nerve palsy
4.2%
Fourth
nerve palsy
12.5%
Thyroid
eye disease
14.2%
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.
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:
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.
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.
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
40
5.0%
Neuro-Ophthalmology Service:
Success Rates for Adult Strabismus Surgery
Without diplopia with prism
glasses following a single surgery
5.9%
Required a
second surgery
7.9%
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.
After strabismus surgery at
the Mass. Eye and Ear NeuroOphthalmology Service, most
patients (92%) were without
diplopia postoperatively, with
or without prism glasses.
Without diplopia
following a single
surgery
86.1%
Neuro-Ophthalmology Service:
Rates of Scleral Perforation During
Adult Strabismus Surgery
Percentage of Patients with Scleral Perforation
10
In calendar year 2014, the Mass. Eye and Ear NeuroOphthalmology 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.
8
6
The Mass. Eye and Ear
Neuro-Ophthalmology Service
maintains low intraoperative
and postoperative complication
rates after adult strabismus
surgery.
4
2
2012 (N = 110)
0
0%
0%
0%
2013 (N = 110)
2014 (N = 120)
41
Neuro-Ophthalmology Service:
Rates of Infection After Adult Strabismus Surgery
Percentage of Patients with an Infection
10
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.
8
6
4
2
2012 (N = 110)
0%
0
0%
2013 (N = 110)
0%
2014 (N = 120)
Ocular Immunology and Uveitis Service:
Percentage of Patients on Systemic Immunomodulatory Therapy
Patients treated with systemic medications (%)
50
40
30
27.2%
19.5%
20
10
19.3%
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.
0
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
2012 (N = 2,525)*
medications. In general, the use
2013 (N = 1,724)
of systemic immunomodulatory
2014 (N = 3,553)
therapy is an indicator of
increased disease severity.
42
Vision Rehabilitation Service:
Vision-Specific Quality of Life Outcomes
NEI VFQ-25 vision-specific quality of life mean scores
100
Patients reported improvement
90
45-66
80
39-46
46-59
on all NEI VFQ-25 subscales
45-54
57-66
with greatest improvement for
55-57
mental health.
70
34-43
30-38
60
50
43.1
50.0
49.0
47.9
41.6
40
47.9
41.4
39.2
30
20
10
0
General vision
Near activities
Mental health
Role difficulties
Pre-Rehabilitation (N = 54)
Post-Rehabilitation (N = 54)
Previous Reported Outcome Studies2,3
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.
2
Scott 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.
IVI vision-specific
quality of life mean scores
3.0
p = 0.03
2.0
1.63
1.29
p = 0.02
1.54
p = 0.02
1.57
1.55
1.14
p = 0.01
1.15
1.19
1.0
0.0
Reading
Mobility
Well-being
When completing the Impact
of Vision Impairment (IVI)
questionnaire, patients are asked
to rate if their eyesight interferes
with everyday activities 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.
Patients reported improvement
on all IVI subscales with greatest
improvement for mobility and
well-being.
Total
Pre-Rehabilitation (N = 54)
Post-Rehabilitation (N = 54)
43
Vision Rehabilitation Service:
Patient Satisfaction Survey
100
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.
92.9%
Quality of Service (%)
80
60
40
20
6.3%
0
0.8%
0.0%
0.0%
Excellent (N = 235) Above Average (N = 16)
Average (N = 2)
Below Average (N = 0) Poor (N = 0) N = 253
100
Ninety-eight percent of patients
reported that the explanation of
their rehabilitation options was either
“Excellent” or “Above Average.”
87.4%
Explanation of
rehabilitation options (%)
80
60
40
20
10.3%
2.4%
0
Excellent (N = 221) Above Average (N = 26)
Average (N = 6)
Below Average (N = 0) Poor (N = 0) 44
N = 253
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
95.6%
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.”
Interaction with staff (%)
80
60
Based on their own
experiences, 100% of
patients said they would
recommend the Mass. Eye
and Ear Vision Rehabilitation
Service to friends or family.
40
20
4.4%
0
0.0%
0.0%
0.0%
Excellent (N = 239) Above Average (N = 11)
Average (N = 0)
Below Average (N = 0) Poor (N = 0) N = 253
45
Ophthalmology Medical Staff
and Practice Locations
Locations
Comprehensive Ophthalmology
and Cataract Consultation
Sheila Borboli-Gerogiannis, MD
Mass. Eye and Ear, Main Campus
Mass. Eye and Ear, Providence
Stacey C. Brauner, MD
243 Charles Street
One Randall Square Suite 203
Han-Ying Peggy Chang, MD
Boston, MA 02114
Providence, RI 02904
Sherleen H. Chen, MD, Service Director
Tel: 617-573-3202
Tel: 401-453-4600
Matthew F. Gardiner, MD
Site Director, Magdalena Krzystolik, MD
Scott H. Greenstein, MD
Kathryn M. Hatch, MD
Carolyn E. Kloek, MD
Mass. Eye and Ear, East Bridgewater
400 N. Bedford Street
Mass. Eye and Ear, Stoneham
Kristine Tan Lo, MD
E. Bridgewater, MA 02333
1 Montvale Avenue
Alice C. Lorch, MD
Tel: 508-378-2058
Stoneham, MA 02180
Zhonghui Katie Luo, MD, PhD
Site Director, Angela Turalba, MD
Tel: 781-279-4418
George N. Papaliodis, MD
Site Director, Matthew F. Gardiner, MD
Christian E. Song, MD
Ryan A. Vasan, MD
Silas Wang, MD
Mass. Eye and Ear, Longwood
800 Huntington Ave.
Mass. Eye and Ear, Retina Consultants
Boston, MA 02115
3 Woodland Road Suite 210
Cornea and External Disease
Tel: 617-398-2947
Stoneham, MA 02180
Sheila Borboli-Gerogiannis, MD
Clinical Director of Ophthalmology,
Tel: 781-662-5520
Han-Ying Peggy Chang, MD
Carolyn E. Kloek, MD
Site Director, Deeba Husain, MD
James Chodosh, MD, MPH, Associate
Service Director
Joseph B. Ciolino, MD
Mass. Eye and Ear, Plainville
Mass. Eye and Ear, Waltham
Reza Dana, MD, MSc, MPH, Service Director
30 Man Mar Drive Suite 2
1601 Trapelo Road
Claes H. Dohlman, MD, PhD
Plainville, MA 02762
Reservoir Place, Ste. 184
Kathryn M. Hatch, MD
Tel: 508-695-9550
Waltham, MA 02451
Deborah S. Jacobs, MD
Site Director, Magdalena Krzystolik, MD
Tel: 781-890-1023
Ula V. Jurkunas, MD
Site Director, Kathryn M. Hatch, MD
Zhonghui Katie Luo, MD, PhD
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
Glaucoma
Optometry/Contact Lens
Retina
Teresa C. Chen, MD
Mark M. Bernardo, OD
Jason I. Comander, MD, PhD
Iryna A. Falkenstein, MD
Shannon Bligdon, OD
Dean Eliott, MD, Associate
Cynthia L. Grosskreutz, MD, PhD
Matt Goodman, OD
Service Director
Ambika S. Hoguet, MD
Yan Jiang, OD, PhD
Evangelos S. Gragoudas, MD, Service Director
Milica Margeta, MD, PhD
Charles D. Leahy, OD, MS
Paul B. Greenberg, MD
Louis R. Pasquale, MD, Service Director
Brittney J. Mazza, OD
Rachel Huckfeldt, MD, PhD
Veena Rao, MD, MSc
Amy Scally, OD
Deeba Husain, MD
Lucy Q. Shen, MD
Amy C. Watts, OD, Service Director
Ivana K. Kim, MD
Brian J. Song, MD
Karen L. Zar, OD
Leo A. Kim, MD, PhD
Angela V. Turalba, MD, Associate
Magdalena Krzystolik, MD
Service Director
Vision Care for the Deaf
Jan A. Kylstra, MD
Janey L. Wiggs, MD, PhD
Andrew D. Baker, OD
John I. Loewenstein, MD
Neuro-Ophthalmology
Pediatric Ophthalmology and Strabismus
John B. Miller, MD
and Adult Strabismus
(in collaboration with
Shizuo Mukai, MD
Dean M. Cestari, MD
Boston Children’s Hospital)
Eric A. Pierce, MD, PhD
John W. Gittinger, Jr., MD
Anna Maria Baglieri, OD
Lucia Sobrin, MD, MPH
Robert Mallery, MD
Kimberley Chan, OD
Demetrios G. Vavvas, MD, PhD
Joseph F. Rizzo III, MD, Service Director
Linda R. Dagi, MD
Richard Watson, MD
Joan W. Miller, MD
Bharti Gangwani, MD
David M. Wu, MD, PhD
Ocular Oncology
Gena Heidary, MD, PhD
Yoshihiro Yonekawa, MD
Suzanne K. Freitag, MD
Melanie A. Kazlas, MD,
Lucy H. Y. Young, MD, PhD
Evangelos S. Gragoudas, MD
Service Director, Mass. Eye and Ear
Frederick A. Jakobiec, MD, DSc
Danielle M. Ledoux, MD
Inherited Retinal Disorders
Ivana K. Kim, MD
Jason Mantagos, MD
Jason I. Comander, MD, PhD
Nahyoung Grace Lee, MD
Robert A. Petersen, MD, DMSc
Brian Hafler, MD, PhD
Shizuo Mukai, MD
Ankoor S. Shah, MD, PhD
Rachel Huckfeldt, MD, PhD
Francis Sutula, MD
Mary C. Whitman, MD, PhD
Eric A. Pierce, MD, PhD, Service Director
Michael K. Yoon, MD
Carolyn S. Wu, MD, PhD
Uveitis and Immunology
Ophthalmic Pathology
Refractive Surgery
Reza Dana, MD, MSc, MPH
Thaddeus P. Dryja, MD
Kathryn M. Hatch, MD
George N. Papaliodis, MD, Service Director
Frederick A. Jakobiec, MD, DSc,
Ula V. Jurkunas, MD
Lucia Sobrin, MD, MPH
Service Director
Zhonghui Katie Luo, MD, PhD
Lucy H. Y. Young, MD, PhD
Rebecca C. Stacy, MD, PhD,
Samir A. Melki, MD, PhD
Associate Director
Roberto Pineda II, MD, Service Director
Vision Rehabilitation
Hajirah N. Saeed, MD
Calliope Galatis, OD
Christian E. Song, MD
Kevin E. Houston, OD
Ophthalmic Plastic Surgery
Suzanne K. Freitag, MD, Service Director
Amy Watts, OD, Service Director
Nahyoung Grace Lee, MD
Daniel R. Lefebvre, MD
Francis C. Sutula, MD
Michael K. Yoon, MD
47
Contributors
Elizabeth Acosta
Anne Marie Donnelly
Patricia Li
Samuel Scott
Olumuyiwa Adebona
Marlene Durand
Michael Lin
Barbara Scully
Shakhsanam Aliyeva
Dean Eliott
Ann-Marie Lobo
Alexandra Selivanova
Bilal Alwattar
Tobias Elze
John Loewenstein
Lucia Sobrin
John Anderson
Kimberly Farwell
Peter Lok
Brian Song
Christopher Andreoli
Tanya Fedyshyn
Alice Lorch
Ravichandran Srinivasan
Olamide Awosanya
Joan Feltman
Migdali Lorenzo
Jennifer Street
Sandra Baptista-Pires
Ashley Femino
Cara Ludwick
Christopher Taylor
Patricia Barthelemy
John Fernandez
Pedro Lugo
Helen Todisco
Linda Belkner
Ruben Fernandez
Katie Luo
Debra Trocchi
Cobi Ben-David
Cherie Florio
Christina Marko
Angela Turalba
Jean Bibeau
Jenna Forgione
Joe Marshall
Edem Tsikata
Bridget Boles
Leila Foster
Maureen Martinez
Joseph Vadakekalam
Sheila Borboli-Gerogiannis
Martha Fraser
Kathy McCormack
Peter Veldman
Stacey Brauner
Suzanne Freitag
Fran McDonald
Christina Venditti
Monica Bynoe
Sandra Gallagher
Lisa McLellan
Merideth Vida
Chris Buliga
Matthew Gardiner
Samir Melki
Kenny Vien
Charlene Callahan
Elizabeth Garlo
Joan Miller
Rhonda Walcott-Harris
Joel Carusone
Sharyn Ghiloni
John Miller
Jay Wang
Dean Cestari
Amanda Goggin
Alfred Minincleri
Suzanne Ward
Kenneth Chang
Evangelos Gragoudas
Nicolas Moretti
Amy Watts
Peggy Chang
Scott Greenstein
Scot Morrison
Lauren Winter
Wendy Chao
Kathryn Hatch
Anne Murphy
Julia Wong
Yewlin Chee
Leo Hill
Michael Navetta
Emily Woodcock
Sherleen Chen
Fariba Houman
Sheelagh Nelis-Swain
Janet Yedziniak
Teresa Chen
David Hunter
Toni Nuzzo
Lucy Young
Sal Chiev
Deeba Husain
Bob O’Hare
James Chodosh
Mary-Lou Jackson
Sheila O’Keefe
Research Fellow:
Catherine Choi
Maryann Jerrier
George Papaliodis
Jing Zhang, M.D.
Jonathan Chou
Yan Jiang
Louis Pasquale
Bo Young Chun
Grace Jonak
Eric Pierce
Study Coordinators:
Janet Cohan
Ula Jurkunas
Roberto Pineda
Laura D’Amico
Louise Collins
Justin Kanoff
Corinne Powers
Madeline Freeman
Lisa Cowan
Melanie Kazlas
Suzette Profio
Greta Covino
Diane Keogh
Andrew Rabkin
Deborah Cronin-Waelde
Ivana Kim
Michael Reinhart
Linda Dagi
Leo Kim
Mike Ricci
Reza Dana
Carolyn Kloek
Debbie Rich
Mindy Davis
Magdalena Krzystolik
Joseph Rizzo
Medical illustrations by:
Suzanne Day
Anne Marie Lane
Marsha Robinson
Laurel Cook Lhowe
Sandy DeCelle
Mary Leach
Alexandra Rondan
Peter Delisle
Eliza-Eve Leas
Debra Rogers
Graphic Design by:
April Dobbs
Daniel Lefebvre
Barbara Ruchie
Marc Harpin, Rhumba
Claes Dohlman
Kathleen Lennon
Charles Ruberto
Erica Donadio
Olga Levy
Mary Savell
48
243 Charles Street
Boston, MA 02114-3096
617-523-7900
617-523-5498 (T.D.D.)
MassEyeAndEar.org