Rethink. Reuse. Reimaging Eye Care.

Almost 40 years ago, in 1987, former Norwegian Prime Minister Gro Harlem Brundtland issued a report with an unmistakable title: “Our Common Future”. Brundtland wrote that sustainable development “meets the needs of the present without compromising the ability of future generations to meet their own needs.” Sustainable development is therefore part of the broader concept of sustainability, an increasingly familiar word that reflects the long-term necessity for continued existence.

As the Latin etymology sustinere suggests, sustain means to hold, to resist, to endure. In essence, to survive. Alarming reports about the impact of pollution, waste, and climate change on global health have revealed threats to our ability to survive. This has inspired ophthalmologists and their scientific societies to start raising awareness and finding solutions. In this regard, the ESCRS has been at the forefront, co-initiating the EyeSustain project and implementing strategies with solid scientific evidence.

Implementation lags behind 

Over the last three years, there has been a significant increase in awareness of this topic, as Diana Silva MD, member of the Young Ophthalmologists for Sustainability (YOFS) of the ESCRS, observed. A 2023 survey of ESCRS members showed that 99% were concerned about global warming and climate change, and 92% felt that operating room (OR) waste is excessive and should be reduced.¹ An earlier survey conducted by David Chang MD in North America showed many similar results.²

In light of these findings, ophthalmology societies are now taking their commitment to sustainability more seriously, with 55 of them joining ESCRS in backing the EyeSustain platform as active partners.

Awareness of and education about sustainability are growing, with the ESCRS actively reducing waste, cutting plastic use, promoting public transportation, and pushing for the use of the SIDICS tool to evaluate the sustainability of cataract packs used by hospitals and surgical centres.

Yet, fully integrating sustainability into ophthalmic practice remains a challenge. “It is quite difficult to implement something that is very disruptive in comparison to what has been done,” Dr Silva said. “It is a big challenge, and I think we are still far from attaining what we need, at least from a global standpoint, in order to decrease the carbon footprint of cataract surgery and ophthalmology in general.”

Some hesitations in implementing more sustainable practices stem from concerns about their safety. In this regard, research is fundamental to convince the ophthalmic community to act.

“We can convince our colleagues by telling them what is happening worldwide with data which have been published over the last few years,” said Oliver Findl MD.

Research on sustainability has grown rapidly, as revealed at the 2025 ESCRS Annual Congress in Copenhagen. From Professor Chang’s initial research at the Aravind Eye Centre in India to recent studies on the safe reuse of surgical materials and hospital waste management, there is evidence suggesting benefits from sustainability in environmental, safety, and cost terms.³ Optimizing patient workflows through telemedicine also helps reduce the carbon footprint, since patients’ travel to clinics and hospitals accounts for a large amount of the carbon footprint in cataract surgery.⁴ 

Yet progress remains slow, particularly when it comes to reusing ophthalmic surgical materials, where the challenges lie partly in regulation and partly in market and industry demands.

Single use versus multi-use

A key step towards sustainable ophthalmology is safely reusing sterilized surgical instruments. Studies comparing outcomes in Aravind and AAO IRIS Registry data show no increase in endophthalmitis, even with phacoemulsification components like cassettes, tubing, and I/A handpieces.

Leading ophthalmology societies, including the ESCRS, recently issued a joint statement urging the development and approval of multi-use phacoemulsification supplies, noting that single-use mandates create unnecessary plastic and energy waste without proven safety benefits over reusable systems.

“In the ’90s in Europe, we used to use a phaco cassette for many procedures, but then we were told that to use a new cassette every single surgery gives you better safety,” Professor Findl, one of the authors of the position paper, said. The data collected in the paper show cataract surgeons strongly support reusable products and call for greater flexibility from regulatory agencies.

As Prof Chang noted in Copenhagen, both the FDA and EU MDR require manufacturers to validate the safety and efficacy of a device for a set number of reuses; without such validation, products are automatically labelled single use. Regulations are, in fact, a barrier to reuse because manufacturers are not prone to invest money and time in studies proving the safety of multi-use products. The current regulatory structure in Europe, Dr Silva explained, allows member states to determine whether single-use devices can be reprocessed in some ways, creating an ambiguous interpretation.

“This is something that not a lot of ophthalmologists are aware of because it is different from country to country— there is no uniform legislation for the entirety of Europe,” she commented. However, there is still no push towards a unified approach, Dr Silva said. “This emphasizes the need for ophthalmologists to become more educated around this topic, to take part in discussions with regulatory agencies and policymakers, and to be involved in the change.”

Concerning the European environment, a BMJ study on 1,000 surgeries in Belgium showed reusable phaco cassettes cut 75% of plastic, saved storage space, reduced costs (€54 per 10 procedures), and sped up priming without compromising safety, confirming the Aravind model is safe, possible, and efficient.⁵

As a matter of fact, some machines in Europe use day cassettes, which are approved and safe, and this can inspire new business models for future ophthalmology, as Prof Findl noted. “The hope is that this will also ignite some innovation in industries—because we need to do this together, surgeons and manufacturers,” he affirmed.

Of course, industry follows the laws of the market, so change is proving difficult despite advancements such as the introduction of electronic instructions for IOLs and OVDs, simplified packaging, recycling products, and rethinking life cycle analysis in favouring more sustainable choices like transportation by boat or offsetting of plastic waste. The path towards multi-use products, however, is still slow and difficult, especially concerning costs in the short term. In this, continuous collaboration is crucial.

The health sector paradox

WHO data demonstrates the health sector is responsible for 4–5% of global greenhouse emissions, creating a paradox: in caring for their patients, doctors may inadvertently harm the environment, which in turn generates further health challenges and burdens for the healthcare system. And for this reason, sustainability is not a trend or a luxury: it is a vital necessity. Such sustainability means optimizing the resources we have, standardizing more sustainable practices, and reducing costs and waste, especially given the expected growth in ophthalmic patients, which will pose even greater challenges in the future. Change must start at the individual level and then expand to the hospital, clinic, staff, and colleagues.

“There are so many ways of doing this. Some of them will have more impact than others, but just look at your processes—the things you do inside the OR, or the clinic, the staff room—and think about how you could do it better,” Prof Findl suggested.

Doctors, their knowledge and their instruments, are pivotal in a change of mindset. They are the driving force behind health and sustainability advocacy, through collaboration beyond frontiers.

“It is about caring for our patients and thinking with our heads, rethinking how we practise our profession and be more efficient, use more technology to help us streamline workflow, reuse more, use different kinds of materials,” Dr Silva said.

Oliver Findl MD, MBA, FEBO is a past president of the ESCRS, Chief of the Department of Ophthalmology, Hanusch Hospital, Vienna, Austria, and Co-Chair of the EyeSustain Global Council. ofindl@googlemail.com

Diana Silva MD, FEBO is an ophthalmologist at Fernando Fonseca Hospital, Amadora, and Hospital da Luz, Lisbon, Portugal, and Co-Chair of the EyeSustain Global Council. diana_silva1@hotmail.com  

1. Chang DF, Elferink S, Nuijts RMMA. 2023 Apr 1; 49(4): 341–347.
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