Needless drug waste in ophthalmology: What can be done?
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Pharmaceutical waste in ophthalmic surgical practice accounts for a significant proportion of medical waste per year.
A large proportion of pharmaceutical waste from cataract surgery consists of topical ophthalmic medications that are unused or lightly used before being discarded. One study by Tauber and colleagues found that among four surgical sites in the United States, 65.7% of eye drops were unused at time of discarding, resulting in unnecessary potential carbon emissions of 711 to 2,135 kg of CO2 equivalents per month. A number of steps can be taken to reduce this level of waste.
The first action point is that surgical centers and hospitals should standardize allowing reuse of multidose eye drops on multiple patients. Such a practice has not been linked to increased rates of endophthalmitis. I collaborated on a study with the Aravind Eye Hospital in Pondicherry, India, in which we videotaped trained technicians instilling preoperative eye drops on patients before cataract surgery and found of the 1,839 recorded instances of eye drop administration, none showed contamination. However, the OICS Task Force OR waste survey found that more than 50% of surgeons are not using multidose medications on multiple patients, owing largely to institution regulations against reuse. A separate study found that a multiuse protocol for dilating drops in the preoperative setting could reduce the number of bottles being used to less than 3% of the original amount, resulting in a 5-year cost savings of approximately $240,000 per institution.
A second point of action is to allow properly stored multidose eye drops to be used until the expiration date set by the manufacturer label rather than an arbitrary number of days from the time of bottle opening. Dr. Wiley Chambers, director of the FDA Office of Specialty Medicine, Division of Ophthalmology, wrote in a 2021 editorial that the widely enforced 28-day use-by date from bottle opening set by regulatory bodies on ophthalmic drug products was never the original intention of The Joint Commission, which imposed these limits on injectable multidose medications but not topical ophthalmic products. This misinterpretation of the 28-day use-by date recommendation has led to partially used eye drop bottles being discarded long before their intended expiration date and resulted in unnecessary drug waste.
Finally, it should be standard practice to allow patients to take home partially used topical ophthalmic medications after eye surgery rather than allowing these medications to go to waste. In a recent survey, only 26% of ophthalmologists send topical medications from surgery home with patients, with the most frequently cited barriers including facility regulations and pharmacy constraints. Due to wide variation in practices regionally, such barriers may need to be addressed at a state level. In 2020, the Chicago and Illinois State Medical Societies introduced a resolution to the Illinois General Assembly, “Topical Operating Room or Emergency Room Medications for Post-Discharge Patient Use,” which allows topical medications ordered at least 24 hours preoperatively and used in the OR to be properly labeled before the unused portion can be given to patients for post-discharge care. Illinois SB579 was signed into law in 2021 as PA 102-0155 with support from multiple physician societies. The model legislation is available on the American Academy of Ophthalmology website and may serve as an example for advocates in other states to enact similar laws allowing for the widespread practice of letting patients take home partially used ophthalmic medications after surgery.
These recommendations are summarized in an AAO position statement released in April 2022 and offer a framework for taking action to reduce unnecessary pharmaceutical waste without impeding patient safety and quality of ophthalmic care.
- References:
- Berkowitz ST, et al. Ophthalmology. 2022;doi:10.1016/j.ophtha.2022.06.023.
- Chambers WA. Ophthalmology. 2021;doi:10.1016/j.ophtha.2021.09.003.
- Chang DF, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.05.001.
- Chang DF, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000267.
- Jensen MK, et al. Am J Ophthalmol. 2005;doi:10.1016/j.ajo.2004.09.020.
- Jensen MK, et al. J Cataract Refract Surg. 2008;doi:10.1016/j.jcrs.2008.05.045
- Palmer DJ, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000184.
- Palmer D. The fight to reduce drug waste: Legislative efforts regarding take-home topical medications. Ophthalmology Management/The Ophthalmic ASC. 2021.
- Reducing topical drug waste in ophthalmic surgery – 2022. https://www.aao.org/education/clinical-statement/reducing-topical-drug-waste-in-ophthalmic-surgery. Published April 2022. Accessed Jan. 2, 2024.
- Tauber J, et al. JAMA Ophthalmol. 2019;doi:10.1001/jamaophthalmol.2019.2901.
- The topical medical waste reduction act. https://www.dropbox.com/s/y7bl1pilh9ftfjc/MedicalWastePacket.pdf?dl=0. Accessed Jan. 2, 2024.
- Wu AM, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.09.029.
- For more information:
- Annie M. Wu, MD, clinical assistant professor of ophthalmology and visual sciences at the University of Michigan Kellogg Eye Center, can be reached at wuann@med.umich.edu.
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