EyeSustain aims to reduce ophthalmology’s environmental footprint
Even during the COVID-19 pandemic, a global health emergency that has killed millions, the WHO called climate change the single biggest health threat facing humanity.
“The climate crisis creates many public health problems related to food, water, sanitation and infectious diseases,” OSN Cataract Surgery Board Member David F. Chang, MD, said. “These problems disproportionately fall on the poorest parts of the globe and the poorest societies.”
Source: Noelle Pensec, BS, CRA
Climate change is not a new threat, but the potential negative health concerns that accompany it have many in the health community, including ophthalmology, considering how their daily actions contribute to the crisis.
“We have to look at this profession wide,” Jeff Pettey, MD, MBA, said. “What is our impact on global warming, and how, as a profession, can we approach this in a more holistic way?”
Chang said the health care system in the United States accounts for nearly 10% of the country’s greenhouse gas emissions, and operating rooms are the largest contributor to this excessive carbon footprint.
“As physicians, we should be concerned about the public health impact of global warming,” he said. “However, because of our large environmental footprint, we in the health care sector are a big part of the problem. Since ophthalmology has the highest procedural volumes in all of medicine, it is our obligation to reduce our excessive waste generation as quickly as possible.”
Three of the world’s largest ophthalmic societies joined together to create a new global coalition, EyeSustain, to mitigate ophthalmology’s impact on climate change and to network and inform the profession about how it can practice more sustainably. EyeSustain, whose medical advisory board is chaired by Chang, was launched on Earth Day at the American Society of Cataract and Refractive Surgery annual meeting in Washington earlier this year and laid out its mission to engage the ophthalmic community about sustainable practices, collaborate with industry to reduce the specialty’s carbon footprint and support research that seeks to reduce ophthalmology’s environmental impact.
“Tackling the global visual impairment and blindness burden will be made infinitely more difficult with what could be on the horizon,” Pettey said. “If we are going to reach the unreached, a fundamental part of that equation is to slow down climate change.”
Regulations and other issues
Ophthalmology, like a lot of surgical specialties, creates a lot of waste. OSN Associate Medical Editor John A. Hovanesian, MD, FACS, said a lot of that waste is driven by regulations.
“There have always been regulations in medicine, but there has never really been a priority placed on the environmental impact of the processes we use,” he said. “What has happened by natural adherence to regulations is that we’ve become very wasteful in creating products that ultimately have to be disposed of that are not very efficiently considered.”
For example, Hovanesian said to think about the amount of waste generated during cataract surgery. In one typical case, he said the amount of waste in an operating room (OR) is about equivalent to the amount of waste a person would generate in a week of ordinary living.
“Multiply that by the almost 4 million surgeries we perform in this country every year,” he said. “The average annual waste in the United States is the amount of waste one person would generate if they lived for 66,000 years.”
That waste starts with the drape that covers the patient head to toe and includes all of the plastic devices and cassettes used throughout the surgery, Hovanesian said. One of EyeSustain’s biggest goals is to find and share information on ways practices can cut down on this OR waste.
“There are many centers in the world and in the U.S. that use only a small drape around the face and neck to create a sterile field for cataract surgery, leaving the rest of the patient uncovered,” Hovanesian said. “Those centers do not have any greater risk for infection or any other adverse events, and yet they are significantly reducing the amount of waste produced.”
When that waste is coupled with the manufacturing processes used to create these common single-use items, the potential to reduce the environmental footprint is significant, Hovanesian said.
While reducing infection is the rationale for using so many disposable products in the OR, Chang said that big data studies from one of the world’s busiest eye centers, Aravind Eye Care System in India, cast doubt on whether single-use medications and supplies provide any measurable safety benefit.
“Their carbon footprint for a single phacoemulsification case is just 5% of what we have here by virtue of reusing as much as they can,” he said. “And their infection rate is no higher.”
OSN Presbyopia Board Member Cathleen M. McCabe, MD, highlighted the difference between Aravind and practices in the West.
“One study looked at the carbon footprint of a single phaco case in the United Kingdom and saw that it was the equivalent of driving a car about 310 miles,” she said. “When done at the Aravind Institute, it was equivalent of driving about 14 miles. We already know that the United States doesn’t compare favorably to the U.K.”
She also expressed concern about some methods for sterilization of reusable items that might include the use of harmful chemicals.
“If we can instead utilize reusables that use steam or heat sterilization, we can see even more improvement,” she said. “Along with the impact of manufacturing, packaging and shipping of those disposables could be minimized by using reusable products that are steam sterilized.”
Barriers and support
Reducing waste is a clear goal for improving sustainability in medicine, but regulations and manufacturers’ instructions for use stand in the way.
“Aravind’s data suggest that many long-held regulations are of unproven benefit, while others developed for general surgery are probably unnecessary for cataract surgery,” Chang said. “For example, our surgical gowns might at most contact some sterile irrigating fluid, and multiple pandemic-initiated studies demonstrated negligible risk of viral (and therefore bacterial) transmission and cross-contamination.”
Going through surgeries day to day, physicians may not be aware of how they are creating more waste. Researchers have started to look at how many prepackaged disposable surgical items go unused and are thrown out.
In a study published in the Journal of Neurosurgery in 2017, investigators cataloged every disposable supply that was unused at the end of 58 neurosurgical procedures. They found that the average cost of the unused items was $653, or 13.1% of the total surgical supply cost, and estimated that OR waste amounted to $242,968 per month, or $2.9 million per year.
While this is an example from a different specialty, McCabe said the waste in ophthalmology is likely similar.
“I was talking to a colleague who pointed out that there was a skin staple remover in every surgery pack that he uses,” she said. “It’s in every single pack, yet no ophthalmologist would ever use it, and it gets thrown away.”
Eliminating wasteful practices like this might seem like a quick and easy win, but it can take time. One area in which sustainable practice did win involved ending the use of the one bottle-one patient policy for cataract surgery eye drops. Hovanesian said that many hospitals established regulations based on a previous understanding of increased infection risks that came along with reusing drop bottles.
“Leading a subcommittee of the Ophthalmic Instrument Cleaning and Sterilization (OICS) task force, David Palmer, MD, and Alan Robin, MD, worked to get a consensus from all of the regulatory agencies that we can use these products until they are expired,” he said.
Comprised of representatives from the Outpatient Ophthalmic Surgery Society, ASCRS, AAO and the American Glaucoma Society, the OICS task force released a position statement in April recommending that multidose bottles could be used on multiple patients until the label’s expiration date.
“The amount of money we’ve saved for the system and the environmental impact this has had has been tremendous,” Hovanesian said. “We all know there’s no risk in doing it. We’ve used drops for multiple patients for years in the clinic, and now we have clear guidance that this is safe and acceptable to do in the OR. It’s just one example of eradicating the bogeyman created by these outdated regulations.”
When it comes to disposable products for surgery, McCabe said there has been some pushback from manufacturers that may think practitioners have no interest in the issue. The OICS task force conducted a survey to explore the attitudes of surgeons, nurses and administrators in ASCs toward surgical waste.
“It showed that, overwhelmingly, people were concerned about sustainability and interested in how they can make an impact,” McCabe said.
Among more than 1,300 individuals included in the survey, 93% believed that OR waste is excessive and should be reduced, 78% believed that more supplies should be reused, 91% were concerned about global warming, and 87% wanted their medical societies to advocate for reducing the carbon footprint of surgery.
“We were shocked at how high the response rate was and how strongly people felt about addressing the problem of sustainability in ophthalmology,” Hovanesian said. “Particularly among younger people in our profession, who realize that they have a long runway to make a difference, there is very high motivation there.”
One of those younger physicians looking to make a difference is Aakriti Garg Shukla, MD, who first started taking an interest in sustainability during medical school.
“It is impossible to ignore how much waste is generated on a given OR day and how this waste may be preventable, especially in ophthalmology,” she said. “It’s clear that we can make changes by mindfully using surgical material and reusing or recycling items.”
During her training, Shukla could see what the world will face during the course of her career.
“The impact of climate change has been readily apparent for a long time. The effects will be felt both professionally and in our everyday lives,” she said. “It’s going to have a huge impact, and it behooves us all to try to make some sort of difference in our own practices, as well as to educate others to do the same.”
Starting EyeSustain
Chang’s team and the ASCRS staff launched EyeSustain earlier this year, but the idea had been brewing for a while. After publishing the OICS survey results and writing an editorial on OR waste in 2020, Chang became aware of multiple independent initiatives to reduce ophthalmology’s carbon footprint.
“These efforts were fragmented and isolated because there was no central platform to share information or resources about sustainability,” Chang said. “This led me to propose the idea of a sustainability website to the ASCRS board.”
Thanks to president Oliver Findl’s strong interest in sustainability, the European Society of Cataract and Refractive Surgeons became a co-sponsor of EyeSustain, followed by the American Academy of Ophthalmology, whose new CEO, Stephen McLeod, also embraced and recognized the importance of this initiative. Moving forward, these three major societies will lead what hopefully will be a collaborative worldwide effort, Chang said.
“We chose the name EyeSustain to focus on both the financial and environmental sustainability of the vital services that we provide,” Chang said. “This is something that all of us, regardless of our age or where we practice, should be concerned about.”
As the co-sponsoring societies, Chang said that ASCRS, ESCRS and AAO will provide the financial backing for EyeSustain. They will next invite other global ophthalmology organizations to become participating societies that endorse the coalition’s goals and promote EyeSustain to their members.
“We envision this becoming a global coalition of ophthalmologists and eye societies,” he said. “The first step is to educate, engage and network our profession to work toward improving sustainability in ophthalmology.”
While awareness is at the top of EyeSustain’s list of goals, Hovanesian, an EyeSustain advisory board member, said members also want it to be a forum for advancing efforts toward reducing the environmental impact of medicine.
“We want to allow clinicians to share ideas with each other about practices they’ve discovered to reduce waste,” he said.
EyeSustain will also highlight how industry contributes to sustainability efforts.
“Industry is starting to step up and do some things internally within their own businesses to reduce their carbon footprint,” McCabe said. “We want to highlight that because that is going to help us reduce the footprint of our specialty as a whole. We hope that with that focus, there will be some friendly competition and help motivate other companies to follow suit.”
To help guide content on the website, EyeSustain has established an editorial board, which Shukla chairs.
“The editorial board is a younger group of ophthalmologists who are committed to spreading the sustainability message in our field,” she said. “We ensure that the content on the website is excellent and fully covers the topic in terms of breadth and depth.”
As the AAO’s liaison to EyeSustain, Pettey hopes to build a bridge to the AAO’s Young Ophthalmologists network and engage its members to become leaders in the sustainability movement.
“The change will come from younger ophthalmologists,” he said. “They are often the ones with the most innovative ideas on where we can go as a profession and how we can impact this. For older physicians, it’s just human nature to stick with the status quo. Younger ophthalmologists don’t yet have a status quo. They are at a point in their careers where they are very mission driven.”
Future steps
Sustainability is a long-term goal, and EyeSustain hopes to build a lasting coalition and long-term relationships to reach that goal.
“We’re forming better relationships with the FDA and with CMS, as well as other entities that regulate ORs,” Hovanesian said. “We want to build a platform that recognizes best practices. We’re looking at creating an EyeSustain seal of approval that companies can earn on an annual basis based on their activities.”
Any change that comes will need to be backed by solid data, Pettey said.
“We need better studies to understand what our impact is,” he said. “We need to look at doing more research to help our understanding of if we have the adequate capability to sterilize reusable instruments, particularly in low-resource settings.”
Change will take time, but Shukla said there are steps every physician and every practice can take immediately to start making improvements. For example, she encourages surgeons to do a 2-week challenge and catalog what regularly goes unused in a surgical pack.
“You’ll be able to find patterns in what you use and you don’t use, and in the third week, try to remove those instruments from the pack,” she said. “This is the perfect kind of thing to get a medical student involved. These kinds of projects get people interested and give them a chance to make actionable change.”
She also said institutions could try to form a “green team” to bring people together and promote sustainable practices.
“Folks who are like minded and are interested in making change as part of a group are almost always more effective than individuals,” she said. “It’s nice to collaborate with other people who are interested in this field.”
Editor's note: If you would like to get involved in this initiative, go to eyesustain.org/get-involved.
- References:
- Chang DF, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000267.
- EyeSustain. https://eyesustain.org/. Accessed June 30, 2022.
- Zygourakis CC, et al. J Neurosurg. 2017;doi:10.3171/2016.2.JNS152442.
- For more information:
- David F. Chang, MD, can be reached at Altos Eye Physicians, 762 Altos Oaks Drive, Suite 1, Los Altos, CA 94024; email: dceye@earthlink.net.
- John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Laguna Hills, CA 92653; email: drhovanesian@harvardeye.com.
- Cathleen M. McCabe, MD, can be reached at The Eye Associates, 6002 Pointe West Blvd., Bradenton, FL 34209; email: cmccabe13@hotmail.com.
- Jeff Pettey, MD, MBA, can be reached at University of Utah Health, 65 Mario Capecchi Drive, Salt Lake City, UT 84132; email: jeff.pettey@hsc.utah.edu.
- Aakriti Garg Shukla, MD, can be reached at Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, 635 W. 165th St., New York, NY 10032; email: ag2965@cumc.columbia.edu.
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