Sustainability and Ophthalmology

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Article initiated by:
Anna March de Ribot, MD, PhD, Francesc March de Ribot, MD, PhD, Sruti Rachapudi MD MBA, Lucy Mudie MD MPH
All contributors:
David Palmer, Jenna Tauber, MD, Andrew Go Lee, MD, Derek W DelMonte, MD, Pamela Davila-Siliezar, MD, Rahul Pandit MD, Noor Laylani, MD, Colleen Halfpenny, M.D., Megan Kasetty, MD, Daniel B. Moore, MD, Leo A. Kim, MD, PhD, Michael T Yen, MD, George.Villatoro, Lacey.Echalier, Leslie Neems, Kendall.Goodyear, Hashem Abu Serhan, Sean Berkowitz MD MBA, Anna March de Ribot, MD, PhD, Francesc March de Ribot, MD, PhD, Flora Lum, MD, Sean Berkowitz MD MBA
Assigned editor:
Review:
Assigned status Update Pending
.


Healthcare sector

The healthcare sector significantly contributes to climate impact through its high resource and energy consumption.[1] It is among the largest Greenhouse gas emissions (GHG) polluters globally,[1][2] [3][4] accounting for 4.4% of the world’s total GHGs in 2019, [5] [6] [7] [8] equivalent to the fifth largest carbon emitter if considered a country.[5]

In the USA, healthcare services contribute nearly 10% of the country’s carbon footprint,[1][2][4][5][6][9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] and it is said that it is the second largest contributor to waste in the USA[6][20] [21] after the food industry.[6][20] In NZ and Australia, healthcare services contribute around 5-7% of total GHG emissions,[5] [9] [11] [14] [15][22] [23] surpassing those of aviation.[22] [23] In Canada, healthcare service release 5% of its GHG emissions 40 and contributes alone to 5-6% of the global healthcare GHG emissions; this disproportionate value becomes evident considering that Canada’s population constitutes less than 5% of the worldwide total.[19] Similarly, the German health sector emits 5% of the overall GHG emissions.[24] [25] The UK’s health system emits 20-22 million tonnes of GHGs annually,[17][26] comprising 3-4% of annual emissions[1] [4] [5] [9] [16] and 25% of all its public sector emissions.[16] [17][26]

Much of the health care carbon footprint is attributed to waste generation, particularly disposable material.[1] For instance, hospitals in the USA produce 7,000 tons of waste daily,[1][21] while Essen University Hospital in Germany produces 9 tons per day.[1] Unintentionally, healthcare is also responsible for other harmful emissions, including 9% of the toxic air pollutants in the USA.[3] Surprisingly, healthcare facilities lag in efforts to reduce, reuse, and recycle.[27] Though, healthcare professionals are responsible for addressing climate change by increasingly treating patients suffering from its effect and implementing changes to prevent further harm.[25]

Cataract Surgery and Other General Medical and Surgical Situations

Cataract is the leading cause of blindness and severe visual impairment worldwide.[28] It is therefore not surprising that cataract surgery is one of the oldest and most commonly performed procedures. In 2019, 29 million cataract surgeries were performed globally, a figure that is projected to increase to 50 million in 2050.[28] Due to the sheer volume of cases, the environmental burden from this single surgical indication has been well-documented.[29] [30] Glaucoma surgeries also generate significant waste, and are predicted to rise 44% in England and Wales over the next 15 years.[31] The waste results vary significantly in several environments, despite having similar results.[15] [32] Recently, global efforts to engage and educate the ophthalmic community about more sustainable practices have been established and unique recommendations have been made. It is becoming increasingly necessary to evaluate well-intentioned but questionable practices based on data regarding cataract surgery outcomes.

The environmental challenge of running an operating room is a systems-level issue. Notable complexities include overhead lighting and ventilation, sterilization of supplies, single-use disposable materials, electricity, and contracts. However, there are environmental challenges unique to running an ophthalmic surgical hospital with a large cataract surgery volume. Due to the nature of ophthalmology’s high procedural volume, ophthalmologists are in a unique position to empower institutions and to lead efforts to make healthcare more economically and environmentally stable.

Surgical Hand Antisepsis

The waterless alcohol-based surgical scrub is strongly recommended for prevention against surgical antisepsis. Despite this recommendation by leading health organizations, water-based scrub techniques remain the mainstay of scrubbing procedures. One leading academic ophthalmology center calculated a savings of 61,631 L of water per operating room (OR) per year using an alcohol-based scrub.[29] Using calculations based on the direct purchase costs of scrubbing materials, water company invoices, and the flow rate of scrub sinks at this single institution, an estimated $280,000 - $348,000 could be saved per OR per year by switching to waterless scrub techniques.[29][30] The economic and environmental impact is a strong justification for conserving water and for shifting to nonaqueous surgical scrubs.

Medical Waste Management

The life cycle assessment (LCA) is a tool used to quantify emissions (to land, air, and water) at each stage in a product’s life cycle. This tool accounts for processes such as the extraction of raw materials as well as the energy used to produce and manufacture the product. It also includes transportation, sterilization, and disposal costs. This methodology allows for the calculation of the carbon footprint of cataract surgery. A recent study by Morris et. al calculated the carbon footprint of a single cataract surgery at a British academic institution.[30]Over 50% of the energy used was estimated to come from the greenhouse gas emissions associated with the production, consumption, and disposal of the products consumed in cataract surgery. The remaining carbon admissions of a single cataract surgery were from either energy use of the building and allotted operating room space, or the mode of travel for each patient during their initial assessment, actual surgery, and follow-up appointments. Therefore, efforts to reduce carbon emissions in the surgical cataract pathway that target the procurement and usage of surgical equipment would have the greatest impact on achieving this goal, as compared to focusing on travel emissions or building energy emissions alone.

The prevailing notion for not reusing tools in the operating room comes from well-intended regulations to decrease infection complications and decrease liability. However, current data suggests that this concern may no longer be valid. Haripriya et. al.[33] report low post-operative endophthalmitis rates after 600,000 phacoemulsification and MICS cases in their retrospective trials. These studies occurred at Aravind Eye hospital, a low-resource hospital in Tamil Nadu, India, that reuses phacoemulsification tips, capsulotomy cystotomes, and irrigation tubing. Although there are limitations of the retrospective study, it suggests that by modeling institutions that have achieved this high rate of success, reuse of surgical tools can be done with a low risk of complications. One chief concern in such cases is the risk of infection, or endophthalmitis. The authors were able to achieve a 3.5-fold reduction in rate of endophthalmitis with the use of intracameral moxifloxacin.[33]

Regarding phacoemulsification, the durability and structural changes to a phaco tip during surgery can affect the emulsification ability of the tip. It is therefore significant when porcine animal studies simulating phacoemulsification surgeries reveal no significant microscopic wear. Tsaousis[34] reports that that there are no ultrastructural differences in eight different types of phacoemulsification tips after five uses in porcine models. Each tip, whether labeled for single-use or multiple-uses, was used in five cataract surgeries with varying density porcine lenses and at an extreme setting of 100% phaco power. These tips were then immediately compared using characterization techniques such as scanning electron microscopy (SEM). There was no significant evidence of microscopic damage, breakage, fissures, or failure.[34] Aravind Eye Hospitals have also implemented other efforts to reduce the environmental emissions of cataract surgeries, for example by installing solar panels to reduce the burden of diesel generators and by installing a wastewater treatment center that repurposes water for gardening and toilets.[35]

Drug Waste Management

Drug waste significantly increases the environmental burden and carbon footprint of cataract surgery. Tauber et. al.[36] examined four U.S. surgical facilities that, on average, discarded $148 worth of medications per cataract case.[36] Each of the four centers analyzed spent $195,200[37] [38] annually on unused pharmaceutical products after routine phacoemulsification.[38][39] [40] This included 65.7% of unused eyedrops, 24.8% of unused injections, and 59.9% of unused systemic medications, Assuming approximately 3.8 million cataract cases per year in the U.S., a total of $560 million in medications are discarded annually. Similarly, a single academic center estimated that it saved $240,000 on 7,000 vitreoretinal surgery cases over 5 years and had a 97% reduction in the number of eyedrop bottles in transitioning to multiuser eyedrop bottles.[41] The potential carbon footprint from unused pharmaceuticals was calculated using greenhouse gas emissions, air pollutant emissions, and water-pollutant emissions from each institution. Per cataract surgery, the discarded drugs amounted to 6-30kg CO2e per case from the unused drugs, equivalent to driving 1,025-6,120 miles in an average passenger vehicle or to burning 47-281 gallons of gasoline monthly. This could amount to 105,000 metric tons of CO2 emissions in the U.S. for all cases per year – the equivalence of “driving a car from Anchorage, Alaska to Miami, Florida [up] to 51,400 times every year.”[36]

Additionally, the lack of patient-specific labelling on multi-dose drug bottles required them to be thrown out and repurchased by the patient in a pharmacy following surgery,[37] [38] increasing costs and decreasing efficiency.[38]

Intracameral antibiotics at the end of cataract surgery have been proven to be more effective in reducing endophthalmitis rates compared to topical antibiotics.[42] Along with the environmental impact of antibiotics, the lenient use of antibiotics is contributing to antibiotic resistance, becoming a significant global health issue.[42]

Notably, an injected bolus of intracameral moxifloxacin, though commonly performed off-label in the United States for prevention of postoperative endophthalmitis, has yet to be validated with prospective randomized trials and level 1 evidence. This is in contrast to the five-fold reduction of endophthalmitis rates documented with the use of intracameral cefuroxime as seen in the landmark European Society of Cataract and Refractive Surgeons endophthalmitis study.[43] As such, no FDA-approved, commercially available moxifloxacin for intracameral injection has been available to surgeons.

The RANZCO launched a guideline in 2021 for reducing cataract surgery waste, where intracameral antibiotics alone in routine surgeries were considered the best practice.[44] In the USA, 24% of those surgeons using intracameral antibiotics have stopped giving postoperative topical antibiotics.[44] Thus, there is a trend towards reducing perioperative topical antibiotic prophylaxis, as several studies reported no additional benefit to topical antibiotics when intracameral prophylaxis is used.[45]

Similarly, per Birtel et al., in uneventful cataract surgery, intra or perioperative topical steroids can be as effective as postoperative cortisone drops therapy,[46] potentially reducing environmental impact.

Regarding multiple-patient drugs, a survey of major ophthalmological societies showed that a high percentage of surgeons would consider reusing topical (97%) and intraocular (90-95%) drugs in multiple patients.[47] The American Society of Cataract and Refractive Surgery supports using multi-dose eyedrops for multiple patients when appropriate safety protocols are followed,[38] as multi-dose eye drops have demonstrated no adverse effects but large cost savings.[38] However, despite the evidence, many practices still insist on using single-dose eye drops due to concerns about cross-contamination.[48]

Surprisingly, far from using the same drugs in multiple patients, there are still settings where surgeons are mandated to discard antibiotic eyedrop bottles immediately after surgery with 80-100% of unused weight, resulting in significant waste and increased costs.[38] However, the FDA has established a testing methodology to set an additional level of protection that enables drug products to be used in multiple patients until the stated expiration date with no limited number of different individuals, as long as they are not specifically labelled for single-use.[49]

In 2019, the Illinois Society of Eye Physicians and Surgeons (ISEPS) surveyed 73 ophthalmologists regarding current OR practices of discarding topical medications.[50] The survey revealed that only 40% of OR medications can be taken home by the patient if the medication was ordered from an on-site pharmacy, and only 30% of OR medications can be taken home if the medication was ordered be an external pharmacy.[50] The main reasons cited for this included the logistical concern regarding counseling patients on taking the medications, the state and facility protocols prohibiting hospital dispensation of inpatient drugs, and inability of the pharmacy to attach patient instruction labels required for a patient to leave with a medication. Mydriatic drops were the most frequently discarded topical OR medication, followed by antibiotic drops/ointments and anti-inflammatory drops.[50] Forty-two percent of ophthalmologists indicated that at least one patient experienced an adverse outcome due to medications not being offered and patients subsequently facing financial and insurance barriers to obtaining necessary medications.[50] Among those outcomes were postoperative inflammation (66%) and infection (21%), suggesting that quality of care is negatively impacted by patients not being able to receive medications directly from the OR.[50]

This study spurred the Illinois Senate Bill 0579 to allow partially used topical drops from the OR and ER for post-discharge patient use, and delegates responsibility to the physician (not pharmacist) for medication counseling.[51] Following this bill, the American Medical Association unanimously adopted a resolution to include the safe use of multidose medications for multiple patients.[52] The resolution also advocates for the involvement of stakeholders, such as ophthalmology state organizations, sponsors, and hospital associations, in achieving these goals.[52] These positions regarding safety of multidose eyedrop use have since been endorsed by the American Academy of Ophthalmology (AAO), the American Society of Cataract and Refractive Surgery (ASCRS), and the American Society of Ophthalmic Registered Nurses ASORN.[53]At the institutional and national level, a collaboration must occur between OR administration, staff, and regulators, with ophthalmology societies and sponsors, to create drug waste policies that mitigate OR waste, allow post-discharge use by the patient, permit multidosing for multiple patients, and improve quality of care.

Non-surgery related eye drop waste

Dry eye disease (DED) is a common reason for ophthalmology visits, ranking third after refractive error and cataracts.[54][55] Estimates suggest that DED affects 350 to 700 million people worldwide and up to 40 million people in the United States.[56] [57] Lubricating eye drops are a common DED treatment but generate significant plastic waste. Recycling rates for these plastics are less than 8.7%, leading to environmental concerns.[58] Promoting preservative-free eye drops avoids the use of harmful preservatives like benzalkonium chloride, but may contribute more to plastic waste.[58][59] Each bottle with a 10 mL capacity weighs 6.5 g, but when the same treatment is in an unidose preservative-free single disposable vial, it generates 120 g a month. [60] Eye drops result in an annual CO2 impact of 7 kg per person, mainly due to plastic production and waste processing. [58]

Anti-inflammatory drugs and autologous serum are alternatives to lubricating eye drops but also generate plastic waste.[61] Eyelid hygiene, punctal plugs, moisture chamber spectacles, and scleral lenses can reduce the need for eye drops and single-use plastic waste.[61][62] Special retention eyewear can increase humidity and comfort, potentially reducing the use of lubricants.[60]

Operating room optimization

The operating room logistics of low-resource and low-staffed eye hospitals such as the Aravind Eye Hospital in India can provide an effective model in optimization of available personnel and equipment. Prior to the COVID-19 pandemic, Aravind was using two patient beds in one operating room.[63] While the surgeon is operating on one patient, the other bed is being prepped for the next surgery.[63] Therefore, the turnover between cases is effectively reduced. With this methodology, these surgeons each perform about 60 cases per day.[63] Even though this assembly-line model may not be easily adapted globally, it is a remarkable approach for its optimization of their surgical staff. With good clinical outcomes and low post-operative endophthalmitis rates, the assembly-line model and reusable instruments policy of Aravind serves as a strong justification for optimizing the operating room for “greener” cataract surgeries.

IOL packaging

32.2%, of general waste generated during cataract surgery comprises packaging materials for intraocular lenses (IOL) and viscoelastic.[64] A notable contributor to this waste is the presence of information leaflets in multiple languages, which are redundant because they are rarely used and could be easily replaced by a link to a website or QR code.[64][6]

To illustrate, in the Cardiff cataract pathway in the UK, the IOL itself weighs less than 1g, while its packaging weighs a substantial 64g, including a 70-page booklet translated into 11 different languages.[26][19]

Most ophthalmic surgical supplies, including intraocular lenses (IOLsS), botulinum toxins, and other devices, come with printed instructions for use (IFUs). These are often bulky and contribute significantly to waste, especially given the high volume of ophthalmic surgeries performed [65] and botulinum toxin injections. These informational leaflets are also often in multiple languages, which is redundant as they are rarely, if ever, read by experienced practitioners. Instead, many efforts within ophthalmology, particularly for cataract surgeries, have been made to advocate for the transition to electronic instructions for use (e-IFUs). Both the European Union Medical Device Regulation (MDR) and the U.S. Food and Drug Administration (FDA) allow for the use of e-IFUs, although the MDR does have certain restrictions for items such as machines, because they are not implants or permanently installed systems.[65]

In 2021, a European trade association for medical technology and devices surveyed over 800 participants of healthcare professionals and hospital administrators from 23 different countries regarding e-IFUs. 88% of healthcare professionals and 90% of hospital administrators preferred eIFUs notably due to ease of access and waste reduction.[66] There is also currently no literature suggesting that e-IFUs are a safety threat to patient care. In fact, many argue that e-IFUs could be more safe due to the ease and speed of updating safety information electronically.[65] Therefore, all ophthalmic devices, whether medical devices or surgical products and systems, should be allowed to have e-IFUs by regulatory bodies. An ongoing issue to widespread global adoption of e-IFUs is that many low and middle income countries do not have regulatory body approval of e-IFUs, unlike the FDA and MDR in America and Europe respectively[65].Surprisingly, over 60 countries currently do not accept electronic instructions for medical devices.[6] This list comprises not only smaller low- to middle-income countries but also larger nations like China, Russia, and South Africa.[6]

Surgical Team Education and Awareness

Many studies regarding preventing ophthalmology device-associated infections have been published to consolidate the differences between surgeon opinions and evidence-based medicine.[50][67] An online survey distributed to the surgical staff of cataract surgeries yielded over 1100 responses, 91% of which expressed concern about climate change, and 93% felt that actionable steps should be taken now to reduce the environmental burden of cataract surgeries.[67] This survey further highlights what the driving factors were for waste in the opinions of the surgeons (77% of respondents) and nurses/administrators (18% of respondents).[67] Interestingly, a surgeon’s preference in tools and equipment was not rated high, but manufacturers’ and regulatory agencies’ opinions were felt to be strong driving factors contributing to waste.[67] In fact, 79% of respondent surgeons preferred reusable over disposable tools if the performance and functionality was equivalent.[67] If the survey responses demonstrate a true willingness from surgical staff to participate in reducing waste, then a standard list of equipment for cataract surgery that contains the least number of materials can be encouraged at individual institutions.

Clinical glaucoma devices

Glaucoma is a common reason for ophthalmology visits. The global prevalence of glaucoma worldwide was estimated to be 76.0 million in 2020 and 111.8 million in 2040,[68] and affects approximately a 2.51% of the population.[68][69] [70] The use of disposable tonometer prisms and lenses is related to waste. Within a single eye department in Boston, approximately 61,115 prisms and 800 lenses were purchased yearly, costing $70,282 ($1.15/prism) and $9,040 ($11.30/lens) per year, respectively, resulting in approximately 109.6 kg of plastic waste.[71] However, non-disposable tonometer prisms and lenses could significantly reduce costs to $6,000 ($0.05/prism) and $11,352 ($2.84/lens) for the first year and $3,000 and $2,270 each subsequent year.[71]

Disposable and non-disposable prisms have proved to be equally effective and accurate in measuring IOP. The use of disposable Tonosafe prisms, which is up to 59% in some UK practices, is probably based on the assumption that they eliminate cross-contamination and the need for disinfection.[71] However, evidence suggests clinical infections transmitted by non-disposable tonometers are low, without a strong case for disposable prism use. Guidelines on disinfection can encourage a shift away from disposable prisms, reducing cross-contamination risk and cutting costs.[72][73][74][75]

Draping

Waste related to surgical draping is another topic of interest. Hu et al. found that a majority of landfill waste generated by oculofacial procedures come from plastics, particularly nonwoven polypropylene. In this waste audit study of one office-based operating room blepharoplasty and one ambulatory surgery center (ASC) operating room (OR) blepharoplasty, the nonwoven polypropylene comprised 45% of office-based OR waste and 47% of ASC-based waste.[76] Nonwoven polypropylene is often a single-use material in medical settings, contributing significantly to landfill waste. This plastic is commonly used in drapes. Therefore, reducing oculoplastic reliance on plastics can significantly decrease procedural environmental impact.

This study by Hu et al.[76] noted that the ASC used a standardized surgical pack that was not specific for blepharoplasty, and was also used for more invasive ophthalmic and otolaryngologic surgeries- therefore, many excess materials and their associated plastic packaging were opened yet unused such as “table covers, full-body drapes, gowns, gloves, sponges, cotton swabs, light handle covers, [and] plastic containers.” This study further highlighted the environmental impact through a life cycle analysis, which revealed that disposable supplies was a significant contributor. On average, each blepharoplasty generated 784 grams of physical waste at office-based ORs and 1323 grams at ASCs, corresponding to 6.42 kg of CO2 emitted and 7.78 kg of CO2 respectively.[76] The reduction of single-use plastics and adopting reusable alternatives instead has significant potential for improved waste management practices and decreased landfill contributions from oculofacial and orbital procedures.

The Environmental Sustainability of Vitreoretinal Practice

Vitreoretinal Surgery

Vitreoretinal surgery and clinics specifically face sustainability challenges from high volume procedures such as intravitreal injections, and surgery using climate-taxing gas tamponades. Surgical opportunities include the use of multidose periperative eyedrops discussed above, which applies to all procedures using routine preoperative dilating drops.[41]

In ophthalmology, retina surgery is one of the more complex operations requiring advanced material and climate-unfriendly gases that generate significant waste and sustainability issues. More than 225,000 vitrectomies are performed annually in the United States, with increasing indications [77] [78] [79] [80] Given the diversity of procedures and techniques used by vitreoretinal surgery, surgical instrument trays can create unnecessary costs especially for rarely used instruments requiring sterilization, processing, and replacement. Routinely studying usage patterns and creating streamlined 7 instrument vitrectomy trays was found to save $7886 - $15772 of annual cost avoidance, and $9588 savings from sterilization, at a single institution. [81]

Gas tamponade

SF6, hexafluoroethane (C2F6), and octafluoropropane (C3F8) are commonly used in vitrectomies and retina surgery.[82] [83] [84] [85] As they persist in the atmosphere far longer than CO2, their global warming potential increases with time.[82] [83] [84][1] They are considered among the most potent GHGs, and SF6 is included in the Kyoto Protocol to be strictly regulated and limited in its use.[82] [83] [84][86] Global warming potential within 100 years is 23,900 for SF6, 9,200 for C2F6, and 7,000 for C3F8.[82]

These gases are used in cases of rhegmatogenous retinal detachment (RRD), macular hole, diabetic retinopathy (including segmentation, delamination, and diabetic vitreous haemorrhage), haemorrhagic posterior vitreous detachment, other causes of vitreous haemorrhage, epiretinal membrane peel, and sub-macular haemorrhage.[83] During surgery, the gases can be released into the atmosphere, eliminated from the body through respiration or the bloodstream, or disposed of as medical waste.[87]

Alternatives have been tested by integrating air tamponade in RRD repair, lowering carbon emissions without compromising outcomes.[83] This highlights the potential of adopting more environmentally friendly practices in retina surgery. Nonetheless, air tamponade may not be suitable for all cases.

To be eligible for air tamponade, RD cases should fulfill certain criteria based on the Pneumatic Retinopexy versus Vitrectomy for Retinal Detachment (PIVOT) trial.[84] These criteria include a single retinal break or a group of breaks, no larger than one clock hour in the detached retina, all breaks in the detached retina to lie above the 8 and 4 o’clock meridian and breaks or lattice degeneration in the attached retina at any location when no proliferative vitreoretinopathy grade C found.[84] The proportion of cases eligible for air tamponade is estimated to be between 27% to 52.9%.[84]

The European-Union wide bad on these gases is controversial given the efficacy of these agents in repair and relatively smaller proportion of industry and societal usage of these gases. [88] Long-acting gas tamponades provide longer retinal support and are more beneficial for certain types of RD, such as inferior RD, large breaks and multiple breaks.[84] Considering the environmental impact, SF6, the most damaging and shortest-acting fluorinated gas, should be replaced with air whenever possible[84] or using lower concentrations of C2F6[82] [83] or C3F8[83] as alternatives.[82] More efficient gas delivery systems can reduce excess wastage.[82]

Gas tamponade is not the only contributor of carbon footprint in vitreoretinal surgery. Life cycle assessment of retinal detachment repair found 51.10 kg CO2eq for PPV, 2.09 kg CO2eq for pneumatic retinopexy, and 12.57 kg CO2eq for scleral buckle.[89]

Retina Clinic

There are myriad opportunities to reduce plastic and other waste in medical retina clinic settings. Multidose drops have been validated as safe with no bottle-to-patient contamination in ophthalmology clinic based on prospective videographic and mcirobiological studies. [90]

Intravitreal Injections

In ophthalmology, intravitreal injections have become one of the most common procedures.[91] In the USA, an estimated 5.9 million intravitreal injections were performed in 2016, and this number continues to rise with the aging population.[92] The UK also saw a substantial increase, accounting for up to 215% from January 2010 to May 2014, making it the most common invasive procedure in ophthalmology.[92] However, this increase in intravitreal injections comes with environmental consequences. Each intravitreal injection, regardless of the anti-VEGF agent used, results in 13.68kg CO2eq.[92][93] Patient travel was identified as the single largest contributor to the carbon footprint, accounting for 10.49 kg CO2eq, followed by the injection pack (2.54kg CO2eq).[92] Additionally, the procurement of bevacizumab, ranibizumab, and aflibercept was found to produce approximately 20kg, 320kg, and 423kg CO2eq, respectively, per injection.[92] Dispensable items implied an expenditure of €2.05 per pack, 0.56kg CO2eq per injection (4%), 240kg of plastic annually and 3.360kg CO2eq per annum based on their annual provision of 6,000 injections.[92]

In a retina center in the USA, it was seen that cold packs (62.5%), cardboard boxes (10.4%), foam coolers (8.4%), and nitrile gloves (6.0%) were the items that contributed the most to overall waste.[91] Among these, the non-biodegradable foam coolers were considered the component of intravitreal injections with the greatest environmental impact, as the inexpensive manufacture promoted it to be single-used, they are bulky, persist in landfills for hundreds of years and imply high CO2 emissions.[91]

Intravitreal injections can be optimized, allowing patients to receive them on the same day as their clinic appointments and safe bilateral same-day injections.[92][94] It is one of the more convenient approaches for both the patient and ophthalmologist.[95] In addition, longer acting agents can reduce carbon footprint especially with reduced procedures and transportation needs. Aflibercept 8mg has been suggested to have lower carbon footprint than aflibercept 2mg in treatment-naive patients with nAMD in the UK.[96]

Postoperative follow-ups after uncomplicated intravitreal injections can be safely reduced, decreasing mobility-associated emissions and travel costs.[97] This change benefits the environment and improves access to healthcare for other patients.[97]Intravitreal packs have items that are often opened and discarded unused,[93] making changes to the material could significantly reduce carbon emissions.[92] The packs can be minimized without compromising the safety or quality of care.[98]

Bevacizumab, available in 100 mg/4 mL and 400 mg/16 mL vials, typically requires only 0.05 mL for intravitreal injection.[99] This process can be done ideally by a compounding pharmacy with sterile precautions.[99] However, when this is unavailable, alternative methods are used, such as aliquoting without the same standards or puncturing the rubber cap multiple times to use the same vial on the same day or over several days until it is finished.[99] Despite the ongoing debate about splitting vials, its potential environmental implications have not been thoroughly studied or demonstrated. Nevertheless, it is reasonable to expect that splitting vials could significantly reduce waste, lower the carbon footprint, and minimize chemicals released into the environment. Emphasizing these environmental benefits could further motivate healthcare facilities to adopt this practice.

There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy.[100] [101] [102] Multidose betadine could be feasibly reused to reduce carbon wastage.[41]

The impact of intravitreal injections is well summarized by Grodsky et. al. [103] Take-back programs, smaller packaging, reusable and biodegradable coolers, multidose packaging, and streamlined packages are endorsed by retina sustainability committees.[103] Multiple stakeholdes will need to collaborate in order to minize carbon emissions. [103]

Conclusions

Ophthalmology, with very high clinic and surgical volumes,[1][8][15][24][31] faces the challenge of the increasing prevalence of common diseases such as cataracts, age-related macular degeneration, glaucoma, dry eyes, retinal diseases and allergies driven by aging, demographic developments and climate change.[24]

Given this context, ophthalmologists have a compelling opportunity and obligation to lead efforts within medicine to make eye care more sustainable by reducing the environmental impact.[24][6]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Lever M, Smetana N, Bechrakis NE, Foerster A. Erhebung und Reduktion der Abfallproduktion im Augenoperationsbereich [Survey and reduction of waste production from eye surgery]. Ophthalmologie. 2023 Sep;120(9):932-939. German. doi: 10.1007/s00347-023-01840-6. Epub 2023 Apr 13. PMID: 37052707.
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  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Chang DF. Tackling the challenge of needless surgical waste in ophthalmology. J Cataract Refract Surg. 2023 Apr 1;49(4):333-338. doi: 10.1097/j.jcrs.0000000000001175. PMID: 36975008.
  7. ↑ Hyland CJ, Yates EF, Gadiraju G, Dey T, Broyles JM. Public Perceptions of Climate Change and Plastic and Reconstructive Surgery. Plast Reconstr Surg Glob Open. 2022 Nov 15;10(11):e4442. doi: 10.1097/GOX.0000000000004442. PMID: 36389612; PMCID: PMC9653180.
  8. ↑ 8.0 8.1 Chang DF, Elferink S, Nuijts RMMA. Survey of ESCRS members' attitudes toward operating room waste. J Cataract Refract Surg. 2023 Apr 1;49(4):341-347. doi: 10.1097/j.jcrs.0000000000001096. PMID: 36975010.
  9. ↑ 9.0 9.1 9.2 Buchan JC, Thiel CL, Steyn A, Somner J, Venkatesh R, Burton MJ, Ramke J. Addressing the environmental sustainability of eye health-care delivery: a scoping review. Lancet Planet Health. 2022 Jun;6(6):e524-e534. doi: 10.1016/S2542-5196(22)00074-2. Erratum in: Lancet Planet Health. 2022 Aug;6(8):e644. PMID: 35709809.
  10. ↑ Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, Schuman JS, Venkatesh R. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017 Nov;43(11):1391-1398. doi: 10.1016/j.jcrs.2017.08.017. PMID: 29223227; PMCID: PMC5728421.
  11. ↑ 11.0 11.1 Goel H, Wemyss TA, Harris T, Steinbach I, Stancliffe R, Cassels-Brown A, Thomas PBM, Thiel CL. Improving productivity, costs and environmental impact in International Eye Health Services: using the 'Eyefficiency' cataract surgical services auditing tool to assess the value of cataract surgical services. BMJ Open Ophthalmol. 2021 May 20;6(1):e000642. doi: 10.1136/bmjophth-2020-000642. PMID: 34104796; PMCID: PMC8141432.
  12. ↑ Chang DF. Needless Waste and the Sustainability of Cataract Surgery. Ophthalmology. 2020 Dec;127(12):1600-1602. doi: 10.1016/j.ophtha.2020.05.002. Epub 2020 Jul 15. PMID: 32682622; PMCID: PMC7361054.
  13. ↑ Mamalis N. Reducing the environmental impact of cataract surgery: Sustainability versus safety: A tradeoff? J Cataract Refract Surg. 2018 Jan;44(1):1-2. doi: 10.1016/j.jcrs.2018.01.001. PMID: 29502595.
  14. ↑ 14.0 14.1 Murray N, Mack HG, Al-Qureshi S. The case for adopting sustainability goals in ophthalmology. Clin Exp Ophthalmol. 2019 Sep;47(7):837-839. doi: 10.1111/ceo.13607. PMID: 31631490.
  15. ↑ 15.0 15.1 15.2 15.3 Namburar S, Pillai M, Varghese G, Thiel C, Robin AL. Waste generated during glaucoma surgery: A comparison of two global facilities. Am J Ophthalmol Case Rep. 2018 Oct 10;12:87-90. doi: 10.1016/j.ajoc.2018.10.002. PMID: 30364583; PMCID: PMC6197147.
  16. ↑ 16.0 16.1 16.2 Power B, Brady R, Connell P. Analyzing the Carbon Footprint of an Intravitreal Injection. J Ophthalmic Vis Res. 2021 Jul 29;16(3):367-376. doi: 10.18502/jovr.v16i3.9433. PMID: 34394865; PMCID: PMC8358765.
  17. ↑ 17.0 17.1 17.2 Chandra P, Gale J, Murray N. New Zealand ophthalmologists' opinions and behaviours on climate, carbon and sustainability. Clin Exp Ophthalmol. 2020 May;48(4):427-433. doi: 10.1111/ceo.13727. Epub 2020 Feb 20. PMID: 32048791.
  18. ↑ Di Simplicio S, Fowler S, Burt S, Hogg HDJ. Cross-sector collaboration for carbon reduction and offsetting in cataract surgery. Br J Surg. 2023 Mar 30;110(4):506-507. doi: 10.1093/bjs/znad024. PMID: 36772812.
  19. ↑ 19.0 19.1 19.2 Taboun OS, Orr SMA, Pereira A, Choudhry N. Factors contributing to the carbon footprint of cataract surgery. J Cataract Refract Surg. 2023 Jul 1;49(7):759-763. doi: 10.1097/j.jcrs.0000000000001204. PMID: 37390323.
  20. ↑ 20.0 20.1 Yap A, Wang K, Chen E, Melhado C, Ahmad T, O'Sullivan P, Gandhi S. A mixed-methods study on end-user perceptions of transitioning to reusable surgical gowns. Surg Open Sci. 2022 Nov 8;11:33-39. doi: 10.1016/j.sopen.2022.10.003. PMID: 36444285; PMCID: PMC9700296.
  21. ↑ 21.0 21.1 Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. 2011 Feb;146(2):131-6. doi: 10.1001/archsurg.2010.343. PMID: 21339421.
  22. ↑ 22.0 22.1 TLatta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. N Z Med J. 2021 Sep 3;134(1541):13-21. PMID: 34531593.
  23. ↑ 23.0 23.1 Ferrero A, Thouvenin R, Hoogewoud F, Marcireau I, Offret O, Louison P, Monnet D, Brézin AP. The carbon footprint of cataract surgery in a French University Hospital. J Fr Ophtalmol. 2022 Jan;45(1):57-64. doi: 10.1016/j.jfo.2021.08.004. Epub 2021 Nov 22. PMID: 34823888.
  24. ↑ 24.0 24.1 24.2 24.3 Deutsche Ophthalmologische Gesellschaft (DOG); Berufsverband der Augenärzte Deutschlands e. V. (BVA). Positionspapier und Handlungsempfehlungen für eine ökologisch nachhaltige Augenheilkunde : Stellungnahme der Deutschen Ophthalmologischen Gesellschaft (DOG) und des Berufsverbands der Augenärzte Deutschlands (BVA) [Position paper and recommendations for action for ecologically sustainable ophthalmology : Statement of the German Society of Ophthalmology (DOG) and the German Professional Association of Ophthalmologists (BVA)]. Ophthalmologie. 2023 Jan;120(1):52-68. German. doi: 10.1007/s00347-022-01792-3. Epub 2023 Jan 10. PMID: 36625883; PMCID: PMC9838365.
  25. ↑ 25.0 25.1 Birtel J, Heimann H, Hoerauf H, Helbig H, Schulz C, Holz FG, Geerling G. Nachhaltigkeit in der Augenheilkunde : Adaptation an die Klimakrise und Mitigation [Sustainability in ophthalmology : Adaptation to the climate crisis and mitigation]. Ophthalmologie. 2022 Jun;119(6):567-576. German. doi: 10.1007/s00347-022-01608-4. Epub 2022 Apr 22. PMID: 35451609; PMCID: PMC9024069.
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  27. ↑ Cameron TW 3rd, Vo LV, Emerson LK, Emerson MV, Emerson GG. Medical Waste Due to Intravitreal Injection Procedures in a Retina Clinic. J Vitreoretin Dis. 2021 Feb 10;5(3):193-198. doi: 10.1177/2474126420984657. PMID: 37006514; PMCID: PMC9979047.
  28. ↑ 28.0 28.1 Cataract Cases to Increase 78 Percent by 2050 - Prevent Blindness. (2016, May 19). https://preventblindness.org/cataract-cases-to-increase-78-percent-by-2050/
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  99. ↑ 99.0 99.1 99.2 Das T, Volety S, Ahsan SM, Thakur AK, Sharma S, Padhi TR, Basu S, Rao ChM. Safety, sterility and stability of direct-from-vial multiple dosing intravitreal injection of bevacizumab. Clin Exp Ophthalmol. 2015 Jul;43(5):466-73. doi: 10.1111/ceo.12489. Epub 2015 Apr 14. PMID: 25545882.
  100. ↑ Bhatt SS, Stepien KE, Joshi K. Prophylactic antibiotic use after intravitreal injection: effect on endophthalmitis rate. Retina. 2011 Nov;31(10):2032-6. doi: 10.1097/IAE.0b013e31820f4b4f. PMID: 21659941; PMCID: PMC4459136.
  101. ↑ Storey P, Dollin M, Pitcher J, Reddy S, Vojtko J, Vander J, Hsu J, Garg SJ; Post-Injection Endophthalmitis Study Team. The role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection. Ophthalmology. 2014 Jan;121(1):283-289. doi: 10.1016/j.ophtha.2013.08.037. Epub 2013 Oct 18. PMID: 24144453.
  102. ↑ Hunyor AP, Merani R, Darbar A, Korobelnik JF, Lanzetta P, Okada AA. Topical antibiotics and intravitreal injections. Acta Ophthalmol. 2018 Aug;96(5):435-441. doi: 10.1111/aos.13417. Epub 2017 Apr 25. PMID: 28440583.
  103. ↑ 103.0 103.1 103.2 Grodsky JD, Schehlein EM, Chang DF, Patel NA, Scott NL, Cole ED, Berrocal AM, Kim JE, Emerson GG; ASRS Sustainability Committee. So Many Injections, So Much Waste: Understanding the Environmental Impact of Intravitreal Injections. J Vitreoretin Dis. 2024 Dec 25:24741264241308496. doi: 10.1177/24741264241308496. Epub ahead of print. PMID: 39726951; PMCID: PMC11669133.
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