Towards Sustainable Ophthalmology Practice

Over the past decade, healthcare greenhouse gas emissions surged 30%, David F Chang MD said in the Practice Management & Development Programme at the 40^th Congress of the ESCRS in Milan. Healthcare currently accounts for about 10% of emissions in the US and about 25% in the UK public sector.ⁱ

With about 70% of healthcare emissions produced by operating rooms and labour and delivery suites, and cataract surgery one of the highest volume surgeries worldwide, ophthalmic practice contributes significantly. And global annual cataract surgery volume is projected to jump to 50 million in 2050 from 29 million in 2019, and its climate impact along with it, Dr Chang explained.

“We are going to have to do so much more surgery to reduce the burden of cataract blindness.”

So, what can be done now to cut cataract surgery’s climate impact? Noting cataract surgery produces about 20 times as much waste in Europe and the US as in India, with no difference in postoperative endophthalmitis, there’s plenty of room for improvement, Dr Chang said. Greatly reduced costs are another benefit.

To give surgeons the tools they need to reduce climate impact while maintaining safety, ESCRS partnered with ASCRS and the American Academy of Ophthalmology (AAO) to create eyesustain.org, which Dr Chang chairs. ESCRS is also developing a cataract surgery sustainability index for disposables to help surgeons identify opportunities to safely reduce resource use and practice costs, and provide benchmarks for evaluating supply tenders, said ESCRS President Oliver Findl MD, also an EyeSustain.org board member.

Drs Findl, Chang, and other presenters highlighted several actions surgeons and programme directors can take now to reduce the environmental impact—and related health risks—of ophthalmic surgery.

USE MULTIDOSE MEDICATIONS

In a 2020 survey, 98% of ophthalmologists were willing to use multidose bottles of topical drugs on multiple patients, but less than half actually did.ⁱⁱ Multidose drug bottles were more likely used in ambulatory surgery centres than hospital-based units, though even in ambulatory clinics, just 12% continued using them until their expiration date—instead throwing them out at the end of the day, week, or month.ⁱⁱⁱ

The waste adds about $150 per case and about 23,000 to 105,000 metric tonnes of unnecessary CO2 equivalent emissions annually in the US alone.^iv To reduce this waste, ASCRS, AAO, and the American Glaucoma Society jointly endorsed using multidose containers on multiple patients, using them until their expiration date, and allowing patients to take home partially used containers for postoperative use, Dr Chang noted.^v

UPDATE SURGICAL PACKS

Standardising surgical device and supply use consistently with lower utilisation programmes within European countries would significantly cut waste, said Dr Findl, who practices in Vienna.

“If we were to reduce all the [supply] packs in Austria to the lower third, we would reduce emissions by 20% to 27%, depending on whether materials were recycled.” Tools for identifying superfluous instruments are available on EyeSustain.org, he added.

ELIMINATE BODY DRAPES, GOWNS, AND EYE SHIELDS

Surgical drapes are a major waste source, with some programmes using full-body drapes and others just ocular drapes, Dr Findl said. “There is a lot of variation within the same country where we all use the same techniques and technology.”

The Dutch Task Force on Sustainable Ophthalmology also recommends against body drapes and eye shields in most uncomplicated cataract cases, said Sjoerd Elferink MD and Redmer van Leeuwen MD.

SHORT-CYCLE STERILISATION

Properly executed, short-cycle sterilisation can save significant energy compared with wrapped full-cycle sterilisation and drying and is effective for sequential-same-day cataract surgery, Dr Chang noted.^vi The Dutch Task Force on Sustainable Ophthalmology recommends employing internal sterilisation departments and reusable sterilisation containers.

REUSABLE DIAMOND BLADES

Reusable diamond keratomes are an option, Dr Chang said. “Our diamond paracentesis blades cost $425 and can last more than a year.”

WATERLESS SCRUB

Using alcohol hand sanitizer to scrub between surgeries can save an estimated 61,631 L of water annually per operating room and $280,000 to $348,000 in scrub time, Dr Chang added.^vii

CALCULATE CARBON FOOTPRINT AND EDUCATE STAFF

Calculating the practice’s carbon footprint and educating staff can make a huge difference, Dr Chang noted.

“If they understand this, they will think of ways to reduce waste.”

Presenting studies that support operational changes is also critical for convincing administrators to change policies. He advised searching EyeSustain.org for its many supporting documents online, adding mygreendoctor.org as another great source for educational materials and supporting sustainable practices.

ⁱ Morris DS et al. Eye (Lond), 2013 Apr; 27(4): 495–501.

ⁱⁱ Chang DF, Thiel CL. J Cataract Refract Surg, 2020; 46: 933–940.

ⁱⁱⁱ Thiel CL et al. J Cataract Refract Surg, 2022; 48: 1092–1094.

^iv Tauber J et al. JAMA Ophthalmology, 2019; 137: 1156–1163.

^v “Reducing Topical Drug Waste in Ophthalmic Surgery – 2022”, American Academy of Ophthalmology, April 6, 2022. https://www.aao.org/clinicalstatement/reducing-topical-drug-waste-in-ophthalmic-surgery.

^vi Chang DF et al. Ophthalmology, 2018; 125: 1320–1324.

^vii Javitt MJ et al. JAMA Ophthalmology, 2020 Apr 1; 138(4): 382–386.

Oliver Findl: oliver@findl.at

David Chang: dceye@earthlink.net

Sjoerd Elferink MD and Redmer van Leeuwen MD: sustainable.ophthalmology@gmail.com