Sustainability and Waste Reduction in Ophthalmology

Dr Soosan Jacob MS, FRCS, DNB As responsible world citizens, we need to look inwards for means to reduce our contribution to climate change and non-sustainable practices. Ophthalmology as a specialty needs to do its part in making a difference. Lasting prosperity needs sustainability - not just industrialisation and economic development but ecological and environmental health and social equity. By definition, sustainable development means making sure we meet our needs while ensuring future generations are not deprived of the ability to meet theirs. A crucial pillar of sustainability is preserving our environment and decreasing our carbon footprint so Earth and its living systems perpetually thrive and continue as a wonderful home for all our future generations. Statistics regarding healthcare contribution to greenhouse gases can be alarming, with most of us probably unaware of the magnitude. For example, the National Health Service contributes one-fourth of the carbon footprint of the public sector of the United Kingdom. The healthcare sector of the US contributes one-tenth of its greenhouse gas emissions. These are possibly extrapolatable to most developed countries to a greater or lesser extent. Sustainability is best adopted when there is a maintained/improved standard of care, reduced cost, and shared goals of responsible behaviour. Ophthalmic patients often need multiple outpatient visits for chronic disorders, each contributing to carbon emissions. Surgical solutions are often needed, and faster, more ophthalmic surgeries can be performed in a short time, leading to increased waste generation—compounded further by the high use of disposables. CATARACT SURGERY’S HIGH CARBON FOOTPRINT Since cataract surgery is one of the most common elective procedures and has a high carbon footprint (one cataract surgery equates driving a car for 500 kilometres), it would be an ideal case study to try and initiate changes in. Small-incision cataract surgery has less carbon footprint than phacoemulsification, however, it is not practical to do this for all cases. Most contribution from cataract surgery is from pharmaceuticals and disposables. A focused approach is needed here. At the moment, organisational hesitancy impedes the adoption of sustainable practices, mainly because of regulatory and practical obstacles to instituting changes. The US, for instance, doesn’t allow phaco tip reuse. Regulatory obstacles are more common in some parts of the world than others. However, even where changes are happening, they are more voluntary than compulsory. In an ideal scenario, regulatory bodies would make adherence to a decreased carbon footprint compulsory while maintaining the framework of safety. But in reality, the converse seems to be the case. Wider awareness is therefore needed to understand sustainable practices need not mean lower standards. Research should be directed towards setting safe and sustainable protocols. Data regarding waste generation from each procedure should be analysed and attempts made to decrease carbon footprint. A recent landmark publication from the Aravind Eye Care System (AECS) that included 85,552 patients studied the effect on postoperative endophthalmitis rates after introducing a set of four temporary operating room protocols as part of COVID- 19 related protocols. These protocols, often mandatory in the West even before COVID-19, included gowning of patients, changing surgical gloves between each case, cleaning OR floors and counters between patients, and having only one patient at a time in the OR for preparation and surgery. No decrease in endophthalmitis rate was found when adopting these measures. And significantly, the rate in more than 3,35,000 cases without these additional measures (0.01%) was less than that reported by the American Academy of Ophthalmology (0.04%), pointing to the futile waste of resources and the increase in carbon footprint introduced by such measures. Possibly the existence of many other such “standard” protocols needs to be revisited. Another study by AECS found its minimalistic yet proven-safe approach generates 5% of the carbon footprint per phacoemulsification as that of the United Kingdom. At the Dr Agarwal’s group of Eye Hospitals, we have dedicated sterilisation units at each of the hospital chain’s 104 branches, with the type and capacity varying depending on type of surgeries performed at each branch. Surgical gowns, cloth drapes, etc., are laundered, sterilised, and reused while minimum standards are set to ensure safety. Larger reusable cotton draping is topped by a smaller, impermeable single-use drape of cellulose/polyethylene. Unlike the West, most surgeries are carried out without the patient sedated, and local anaesthetic vials are shared. These measures are not unique to us alone. Many other large and small volume centres in the developing and underdeveloped world share these protocols as well as the protocols adopted by AECS. These include autoclaving and reusing drapes and surgeon’s gowns as well as sharing anaesthetic vials, dilating drops, multidose medications, irrigating solutions, intra-ocular drugs, etc. Irrigation/aspiration tubing, phaco tips, vitrectomy sets, etc., are sterilised and reused a certain maximum number of times until efficiency starts to drop. Sustainability should and indeed is already being widely implemented by our specialty via various other measures too. TECHNOLOGY ADOPTION Ophthalmology has always been at the forefront of technology, and COVID-19 helped hasten this trend. Many services and meetings can be effectively conducted online. Tele-ophthalmology and camp services introduce great efficiency into primary and secondary care centres, reducing the need for travel by both patients and specialists and making possible decentralisation of specialised opinion and care. Easy capture and quick transmission of slit-lamp images and digital diagnostic outputs by opticians, optometrists, or even trained personnel allow rapid and accurate clinical and surgical decisions and even cross-subspecialty consultations. Camp/mobile screening services and diagnostic/surgical units can reach large catchment areas and provide specialist care. The Orbis Flying Eye Hospital—with operating and recovery rooms, classrooms, etc., on the plane—is one such example. Artificial Intelligence and machine learning can detect (with high sensitivity and specificity) certain diseases such as diabetic retinopathy, while predictive modelling can suggest treatment guidelines that can act as a base to make decisions or refer if required. Tele-education helps facilitate training and mentoring remotely. At the Dr Agarwal’s Eye Hospital, an extensive network of electronic medical records and digital communities makes it possible to give instant opinions, educate, and train while also making follow-up of patients possible from anywhere in the world. Cloudbased EMR helps decrease the need for paper, large physical storage spaces, and related disadvantages. Efficient supply chains and logistics help prevent wastage of material, transport, and manpower and thus decrease carbon footprint. VOLUNTARY AND CHARITABLE WORK Preventive eyecare, charity-based screening, and surgical camps are widely adopted practices, especially in parts of the world such as India and Nepal. Screening in large areas such as communities, elderly care homes, and schools is an efficient way to enhance community health while decreasing carbon footprint. Investing in preventive health strategies avoids the high carbon output from treating disease in the future. Primary, secondary, and tertiary care centres, hub, and spoke models—as well as shared-resource practices—decrease resource requirements, optimise utilization, and make care available while contributing towards local economy and self-sufficiency by bringing balance between urban and rural development. We need to do still more. Equipment manufacturers should be motivated to make remote access and remote capturing possible. Decreasing equipment size while increasing or maintaining sensitivity, specificity, and operating/software prowess is important. One example is the virtual reality perimetry the AVA™ (Elisar, India), which is as accurate as the Humphrey perimeter but handheld and easily portable. Efficient water taps, lighting designs, optimal energy utilization techniques, efficient IT systems with decreased environmental footprint, and clean energy sources such as solar or wind energy should be incentivized. Just as carbon taxes and carbon trading schemes encourage energy conservation, it is time that safe and scientific reduction of surgical waste and adoption of other sustainability measures are incentivized and celebrated by all stakeholders. As parents, we intuitively try and ensure for our children a future with a good home and the right environment. So why then is there hesitancy in adopting sustainable practices? Advocacy is needed by individuals as well as state, national, and international level ophthalmic societies and organisations to remove regulatory and practical obstacles to instituting change. Other involved associations such as national medical and nursing associations and regulatory bodies need to be made aware of the difference in ophthalmic surgeries compared to nonocular specialties. The industry and manufacturers should be encouraged to make reusable options, and the logic behind many of the “single-use” directives should be re-examined. The “reuse is misuse” philosophy adopted by health systems needs to change. In addition, our practice as a specialty needs to adopt general principles of sustainability that are universally applicable. We owe it to our children to play our part in allowing them to have a world not ravaged by climate change, loss of biodiversity, depleted natural resources, and all the consequences arising from these. Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com.