Tackling Waste in Retinal Surgery

Intravitreal injections are one of the most common proce­dures in ophthalmology, but they come with significant environmental consequences in waste generation and carbon emissions. Although improved sustainability in retinal disease treatment is definitely achievable, it requires awareness and optimization of each clinic’s protocols and routines to make a tangible difference, according to Redmer van Leeuwen MD, PhD.

“To achieve waste reduction in intravitreal injections we need to apply the three ‘Rs’: rethink, reduce, and recycle,” he said. “First, we have to ask if this intravitreal injection is mean­ingful and necessary. The most sustainable injection is the one you can skip. To reduce, we have to ask if we really need all these disposables. Be critical and take on the challenge with the manufacturer and get them to reduce plastic packaging, which is thrown away every time. And finally, we need to recycle, as waste separation saves money and increases awareness.”

Dr van Leeuwen explained his own epiphany in sustain­ability came in 2019 when his clinic in Utrecht mandated a move from reusable equipment to single-use disposable packs. “Initially, it went smoothly without any major objec­tions, but there was a huge amount of waste, and I refused to continue with that approach,” he said.

Part of the solution came from recycling paper and plastic packaging that came as part of the disposable surgical packs, while significant waste reduction came after selecting a new disposable pack with the manufacturer.

The upshot of these measures was a more than 50% reduc­tion in total waste per injection, a 75% reduction in hospital waste and carbon footprint, and a 30% reduction in costs, Dr van Leeuwen said.

To try to extend the benefits of such an approach to other hospitals and clinics in the Netherlands, Dr van Leeuwen and Sjoerd Elferink founded the Dutch Working Group on Sustainable Ophthalmology and published best practice guidelines on administering intravitreal injections in a safe and sustainable way.

“Based on the guidelines of EURETINA and the Amer­ican Academy of Ophthalmology, we made a list of evi­dence-based protocol for intravitreal injections, which has now been adopted as standard practice by the Dutch Ophthal­mic Society,” he said.

The list divides surgical equipment into three cate­gories: essential, optional, and superfluous. Essential equipment includes face masks, gloves, anaesthetic eye drops, povidone iodine drops, and sterile eyelid speculum; optional equipment includes marker/calliper, cotton buds for applying iodine, and non-sterile gauze and non-sterile fluid for removing iodine and eye ointment; superfluous equipment includes drape, cotton swap for anaesthesia and massage, forceps, cap, jacket, tablecloth, and antibiot­ics pre- and post-injection.

Beyond intravitreal injections, other concrete measures can help reduce the environmental impact of retinal surgery, said Francesc March de Ribot MD, PhD.

“We don’t have to try to reinvent the wheel,” he said. “There are small steps we can take immediately, following some of the guidance available to make our surgeries more sustainable, economic, and environmental.”

One such measure is to stop continuous operating theatre ventilation and only enable it 30 minutes before surgery, which can generate up to €2,000 a year in electricity savings. Another simple measure is to save water by using alco­hol solutions instead of sponges for hand disinfection.

“This can save up to 50 litres of water per surgery, which is a major impact,” he said. “And this does not increase the risk of infections, as alcohol hand rub pro­vides superior disinfection for a longer duration.”

Reducing topical drug waste is another simple mea­sure that can make a real impact on sustainability, added Dr March de Ribot. “Studies have shown that preoper­ative drugs in multidose containers are safe to use on multiple patients if proper guidelines are followed and patients requiring a topical medication not used for other patients should be allowed to bring that partially used medication home for postoperative use,” he said.

Using a lighter, perhaps reusable face drape instead of a full body drape should also be considered, as 20% of the waste during eye surgery is due to the plastic face drape, Dr March de Ribot added.

“Bigger drapes are not safer but create more anxiety for the patient,” he noted. “Face drapes allow better ven­tilation, less hypercapnia, gas consumption, and claustro­phobia and are more comfortable for the patient.”

Taking such small measures to save electricity, water, and medications and reduce waste can translate into significant savings annually for every clinic or hospital, Dr March de Ribot concluded.

This article is based on presentations given at the EURETINA Congress in Amsterdam.

Redmer van Leeuwen MD, PhD is an ophthalmologist and vitreoretinal surgeon at University Medical Center Utrecht, Netherlands. r.vanLeeuw­en@umcutrecht.nl

Francesc March de Ribot MD, PhD is an ophthalmologist at the University Hospital of Girona, Italy. march.professor@gmail.com