EyeSustain focuses on sustainability solutions with widespread agreement
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When she started a career in medicine, Emily M. Schehlein, MD, wanted to make an impact.
While she has helped a lot of people in her practice, she felt like she could do more. That is how she got involved with EyeSustain, the multi-society initiative to tackle some of the biggest sustainability issues in ophthalmology and medicine at large.
“You can take care of a lot of patients over your career, but you’ll never be able to take care of all the patients,” Schehlein said. “Creating a sustainable future for our patients will allow us to really extend our reach far beyond our personal patient population.”
When the WHO labeled climate change as the leading threat to global health, Schehlein took action and joined EyeSustain’s editorial board to help other physicians learn how to implement sustainable habits in their practices.
“Climate change is not separate from health, it’s not separate from practicing medicine, and it’s actually fully integrated,” she said. “As physicians, we sign up to do no harm, and that’s really a duty that we take to heart. That’s just part of my practice — to take care of patients in all facets of medicine.”
Ophthalmologists are in a unique position to make an impact because of the sheer volume of cases they handle. According to David J. Palmer, MD, cataract surgery is the single leading surgical procedure in the United States and worldwide. Millions of procedures per year produce a lot of waste.
“We’re in a unique position because of the number of cases we perform and the amount of waste and garbage produced,” he said. “We can look at our initiatives to collectively band together and perform studies together to look at greenhouse gas emissions.”
A 2020 survey co-written by Healio | OSN Cataract Surgery Board Member David F. Chang, MD, showed that virtually all ophthalmologists were concerned with the amount of waste they were creating. Chang said this sparked discussions that led to the creation of EyeSustain (www.eyesustain.org).
“Back then, this was not a topic that ophthalmologists were even talking about, but that survey really highlighted how similarly we all felt about needing more sustainable solutions,” he said. “But there was no platform to discuss ideas or to coordinate our efforts.”
Without a central hub for communication and education, people were left confused about what protocols to follow, and efforts to make changes were fragmented, said Chang, who chairs the EyeSustain advisory board.
“EyeSustain is designed to be that network that allows ophthalmologists to educate each other, as well as our clinic and operating room staff, about the impact of our waste and also to support advocacy, research and innovation,” he said.
In December 2022, the American Society of Cataract and Refractive Surgery, the European Society of Cataract and Refractive Surgeons and the American Academy of Ophthalmology entered a formal agreement to jointly co-sponsor EyeSustain. An additional 45 global ophthalmology societies have become EyeSustain member societies.
“The requirements include forming a sustainability committee and including sustainability in their educational programs,” Chang said. “We can now speak with a united voice to the surgical manufacturing industry about the need to develop more reusable and sustainable options and to show manufacturers that we, as surgeons, care about responsible use of resources and unnecessary amounts of waste.”
That relationship with industry is a key component to EyeSustain’s mission. Healio | OSN Associate Medical Editor John A. Hovanesian, MD, FACS, said the trend for at least the last 10 years has been a push toward single-use, throwaway surgical products with little attention to the amount of packaging waste.
“It’s led to a situation where the average human who goes through cataract surgery in the U.S. generates as much waste from one eye procedure as they do from an entire week of normal living,” he said. “If you add up all the cataract surgeries done in the United States, it adds up to the same amount of waste that a single human would generate if they lived for 66,000 years. It’s a staggering amount of waste, and somebody needs to speak for the planet and consider the amount of plastic we’re throwing away.”
Topical drug waste
In the 2 years since EyeSustain launched, Hovanesian said it has focused on solutions with widespread agreement and a real path toward change.
“What EyeSustain has been trying to do is aim for the low-hanging fruit — the easy wins that everybody agrees on that may have a pathway toward regulatory change,” he said.
EyeSustain’s first waste-reducing initiative focused on perioperative eye drops and ointments. Palmer was one of the lead authors on a multi- society position paper that established recommendations on reducing topical drug waste.
The main recommendations were to allow drugs to be used in multiple patients, to allow topical drugs to be used until the manufacturer’s labeled expiration date and to let patients bring home partially used medication for postoperative use. Palmer and his fellow authors said these changes could be made without jeopardizing patient safety.
“Several accreditation organizations supported our recommendations that patients could go home with their medications and that they could multidose safely,” Palmer said.
Working with the Illinois Society of Eye Physicians & Surgeons, Palmer set out to cut through regulations and hospital protocols to make it easier for patients to take home their medication after cataract surgery. The policy already existed in Illinois, but he found that many hospitals were writing their own policies to get around the state’s rules.
Palmer sent a poll to physicians across the state to determine their experiences and found that only 40% were allowed to send their patients home with medication.
“The reasons we found out through this survey were that, No. 1, hospital pharmacies may be understaffed, and they weren’t able to label the medications properly before discharging them out with the patients to their homes,” he said. “We also found that there were difficulties in providing post-surgical counseling on medication interactions and side effects. The hospitals, instead of overwhelming and overburdening their pharmacists, would write their policies to circumvent Illinois law.”
Through Palmer’s efforts, along with help from the Illinois State Medical Society, the Illinois legislature passed a law to require hospitals to send medication home with patients while allowing for certain stipulations.
“We had to order the medication more than 24 hours in advance, and physicians, not pharmacists, would provide the counseling care that the patient would require,” he said.
This experience working with government is an example of what EyeSustain is hoping to accomplish. Using a single voice representing multiple societies allows the organization to provide information to state legislatures and encourage them to pass similar laws.
The AAO has a template for legislation called the Topical Medical Waste Reduction Act that includes everything states might need to create a law that would allow patients to take their medication home, including a list of frequently asked questions and a sample press release.
Palmer said a few other states have followed suit, but traction has generally been slow.
“Enacting legislation is a very slow process,” he said. “This now involves communication with physicians, administrators and our state societies but also communication with other specialties. In Illinois, we aligned with dermatology, plastics, ear, nose and throat, and emergency physicians to help us with this cause. They too were experiencing similar issues. Our hope is that this evolves to affect all 50 states.”
Instructions for use
Drug waste is just one topic EyeSustain is looking to address. Another major driver of waste and carbon emissions is device packaging, particularly instructions for use (IFUs) in IOL and other device packages. These sheets are packed into IOL boxes and provide information in multiple languages on how to use the lens.
“In the case of lens implants, where we select the lens implant long before the surgery happens, having an instruction for use in the box is almost useless,” Hovanesian said. “It almost never gets looked at because it contains information that we already knew beforehand. That’s why we chose the lens. We almost never refer to it in the OR.”
In a position paper endorsed by AAO, ASCRS and ESCRS in 2023, EyeSustain took an in-depth look at IFUs and how a change to an electronic version might benefit physicians, industry and the environment.
According to the paper, an IOL makes up less than 1 g of its total packaging weight of 64 g. Meanwhile, it comes with a 70-page IFU booklet translated into 11 languages.
Schehlein, co-chair of the EyeSustain task force that developed the paper, said that several papers they found determined that transitioning to an electronic version of the IFU could provide an 84% reduction in paper, or about 50,000 reams of copier paper, each year.
“That’s a huge amount of paper that we could reduce,” she said. “It would make sense to have the instruction for use available in a digital version.”
EyeSustain distributed a survey to device manufacturers in coordination with the Medical Device Manufacturers Association and found that industry agreed. Schehlein said 95% of respondents thought electronic IFUs were an acceptable alternative to paper IFUs. Eighty-four percent thought that electronic IFUs would reduce paperwork from products, and 80% thought it would reduce production costs. One anonymous company told EyeSustain that it was able to reduce IOL packaging weight by 53% by removing the paper IFU where allowed.
“This would decrease packaging size and waste and reduce shipping costs,” Schehlein said. “This is kind of a smart decision for everyone — our industry partners, our patients and the global environment as a whole.”
However, there are barriers to widespread use of electronic IFUs. While they are allowed in the United States and some other countries, they are not universally acceptable. This makes it difficult for industry to make the environmental choice, Hovanesian said.
“If you’re a company who makes the lens implant, you want to get the same package all over the world,” he said. “It doesn’t make a lot of sense to package it in one way for one country and another way for another country.”
The electronic IFU position paper is a call to action and an example of how EyeSustain wants to oppose regulations that stand in the way of sensible changes that would benefit the environment and medicine as a whole.
“Our strategy is to, No. 1, inform ophthalmologists and industry partners about their country’s outdated regulations and start to motivate grassroots activism,” Schehlein said. “The next step is partnering with eye care societies so that they can help work with government leaders in their particular locations to actually make these changes.”
Regulatory barriers are a major challenge, Chang said.
“There are far too many regulations that focus on theoretical risks to an individual without considering the overall economic and environmental cost of those regulations to society,” he said. “We end up with inflexible rules that are not supported by any evidence, such as mandatory single use of many ophthalmic surgical supplies.”
Chang said guidelines that make sense for general surgical procedures are usually applied to eye cases by default, even when they might not make sense.
“After cataract surgery, you are supposed to clean the OR counters and, in some institutions, mop the floor before you can bring another patient in to avoid microbial cross contamination,” he said. “That might be advisable if blood was aerosolized by drills during a hip replacement, but it doesn’t make any sense for a cataract operation.”
Another area that EyeSustain is looking to change is in products that are labeled for single use that might not need to be, such as the tip used on phacoemulsification devices.
“Those can realistically be used for many cases, yet they’re labeled as single use,” Hovanesian said. “For something to be labeled for multiple uses, there is a huge burden of proof of its safety that lies on the manufacturer.”
This does not create a lot of incentive for industry to push for multiuse products, he said. However, EyeSustain hopes to establish a designation that lies somewhere between disposable and multiuse.
“Basically, it would say ‘use for multiple cases has not been validated,’” he said. “It’s a practice of medicine issue, much like using a medication off label is a practice of medicine issue. A doctor can choose to use aspirin to treat heart disease, and there’s a lot of research that supports it even though the FDA has never approved it for that use.”
The EyeSustain surgical facility pledge
Following its launch, EyeSustain has garnered a lot of interest, and Chang hopes it has prompted physicians to rethink ingrained practices in some way. To help guide that initiative, EyeSustain has created an online pledge for individual eye departments and surgical facilities.
“It takes just one motivated individual to approach their department or ASC leadership about signing this symbolic pledge. There’s nothing that’s onerous,” Chang said. “Most of the suggestions improve efficiency and reduce costs, waste and environmental impact. ... We hope that facilities will add their names to the EyeSustain pledge wall as a way to encourage others to do the same.”
The pledge includes seven points: educate surgeons and surgical staff about sustainability and the impact of operating room waste; regularly evaluate surgical pack standardization to minimize waste; use multidose bottles of topical medications on multiple patients until the labeled expiration date; assess the necessity for patient gowns and full body draping; regularly reassess options for reusable vs. single-use products and instrumentation; assess feasibility of alcohol-based scrub for presurgical antisepsis; and institute or update recycling strategies.
Hovanesian said these might be smaller changes on the grand scale of the issues of sustainability and climate change, but getting as many people as possible on board with incremental changes can make a big difference.
“The problem of sustainability does not get solved by a few people doing a perfect job of practicing sustainability,” he said. “It gets solved by everybody doing a small part to make changes where they can.”
Click here to read the Point/Counter, “What is one thing ophthalmologists can do to make their practice more sustainable?”
- References:
- Chang DF, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000267.
- Reducing ophthalmic surgical waste through electronic instructions for use (eIFU). https://eyesustain.org/-/media/eyesustain/pdfs/eifu-multisociety-position-paper-final-121123.pdf. Accessed Feb. 27, 2024.
- Reducing topical drug waste in ophthalmic surgery. https://eyesustain.org/-/media/eyesustain/pdfs/topical-drug-position-statement-final-4122.pdf. Accessed Feb. 27, 2024.
- The topical medical waste reduction act. https://www.aao.org/Assets/8930f457-411f-453f-b1d8-c50597ca4d49/637846801247600000/medicalwastepacket-pdf?inline=1. Accessed Feb. 6, 2024.
- For more information:
- David F. Chang, MD, of Altos Eye Physicians in Los Altos, California, can be reached at dceye@earthlink.net.
- John A. Hovanesian, MD, FACS, of Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
- David J. Palmer, MD, of Northwestern Medicine Department of Ophthalmology in Chicago, can be reached at dapalmer@nm.org.
- Emily M. Schehlein, MD, of Brighton Vision Center in Brighton, Michigan, can be reached at emschehlein@gmail.com.
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