Surgeons committed to improving sustainability in ophthalmology recently connected for a discussion on efforts to reduce waste in practice and in the OR. This article features some highlights of that discussion among David F. Chang, MD; Cathleen M. McCabe, MD; Audrey Talley Rostov, MD; Aakriti Garg Shukla, MD; and Emily Schehlein, MD.

Toward Greater Sustainability in Ophthalmology | Dr. Chang

Risk management and regulations govern a lot of policies in ORs, but there is a consensus among peers that more sustainable practices are needed in ophthalmology, Dr. Chang said. He noted that the insignificant amount of blood and bodily fluid contamination differentiates ophthalmic procedures from others; for example, ophthalmologists had to develop specialty-specific guidelines to defend short-cycle sterilization for sequential same-day cataract surgeries.^1,2

EyeSustain is a global consortium of ophthalmic societies and their members who want to advance the sustainability of eye care and surgery. Co-sponsored by the AAO, ASCRS, and ESCRS, Eye Sustain has more than 2 dozen global member societies that aim to network and collaborate on influencing regulatory policies and the surgical manufacturing industry. The website centralizes resources for ophthalmologists to reduce surgical waste and the environmental impact of their practices, Dr. Chang said.

Pharmaceuticals: Reducing Waste and Saving Money in the OR | Dr. Shukla

The ASCRS has supported the perioperative application of multiuse eye drops since 2012, but many practices still require single-use eye drop administration, Dr. Shukla explained. A multisociety position paper³ published last year concluded that “Topical drugs in multidose containers can be used on multiple patients and until the labeled date of expiration.” Other strategies for reducing waste and saving significant costs include using drop bottles until expired4 and allowing patients to take home eye drops used in surgery.⁵

The financial impact of multiuse versus single-use medications is significant, Dr. Shukla said. Berkowitz et al6 found a cost savings of $240,000 over 5 years in practices that adopted a multiuse dilation protocol before surgery, and a savings of $41,801 over 5 years by practices that adopted a protocol of multiuse betadine before intravitreal injection.

General Waste Reduction in the Ophthalmic Practice | Dr. Talley Rostov

Several efforts can be undertaken to reduce waste in the ophthalmic practice, Dr. Talley Rostov explained. These include partnering with industry (for example, on a push to replace paper instructions for use with digital ones and to minimize product packaging) and replacing single-use instruments and devices with multiuse ones. For presurgical scrubbing, switching from water-based to waterless scrubbing with alcohol can save more than 61,000 liters of water and between $280,000 and $348,000 per year⁷; multiuse containers of surgical scrub (rather than individually packaged scrub brushes) and visible reminders to turn off the water when not in use can also make a difference.

Dr. Talley Rostov suggests taking a 2-week challenge to consider what is in your surgical pack and identify which items you do not use. Doing this for 2 weeks will illustrate where you might reduce waste per case.

The Aravind Eye Hospital as a Model of Sustainability in Medicine | Dr. McCabe

Aravind Eye Hospital applies a low-carbon model of eye care that includes its infrastructure (eg, using solar power and its own water-treatment facilities), travel reduction (eg, on-campus housing for staff, treating family members at the same visit, and providing follow-up visits at 79 affiliated vision centers), and preventative maintenance on all equipment to extend its life, Dr. McCabe explained. Efficiencies in patient flow and work processes minimize patients’ movements within the clinics. For example, patients complete all examinations and testing on the same day, with no waiting period for surgery.

Hospitals in the United States and United Kingdom have 20 times the carbon footprint as the Aravind Eye Hospital when performing cataract surgery with phacoemulsification,⁸ yet these Western countries have four times the rate of postoperative endophthalmitis as Aravind.⁹ The hospital has a stated policy to reduce, reuse, and recycle wherever possible, Dr. McCabe said.

Research Project | Dr. Schehlein

In her third year of medical school, Dr. Schehlein undertook a research project with another resident in which they measured the waste produced from cataract surgery performed at two tertiary care centers of the Aravind Eye Care System, Tamil Nadu and Andhra Pradesh.⁸ As a student, Dr. Schehlein had no preconceived notions about how things were “supposed” to be done in the ophthalmic surgical setting; she therefore had the luxury of questioning ingrained protocols.

Dr. Schehlein noted that Aravind generates 250 g of waste per phacoemulsification and nearly 6 kg of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes.

Additional Notes

EyeSustain will be exhibiting and participating in courses at the 2023 ASCRS Annual Meeting in San Diego.

• Course info: 2023 ASCRS Annual Meeting Instructional Course: Making Ophthalmology Sustainable: Reducing Your Overhead and OR Waste
  • Monday, May 8, 2023; 10:15–11:45 AM
  • Session ID: 11572

Individuals interested in getting involved with EyeSustain can contact Dr. Shukla (ag2965@cumc.columbia.edu) and Dr. Schehlein (emschehlein@gmail.com). The organization is particularly in need of volunteers who are skilled at social media and communications.

For more recommended reading, check out Infinite Vision: How Aravind Became the World's Greatest Business Case for Compassion.

1. Chang DF, Hurley N, Mamalis N, Whitman J. Evaluation of ophthalmic surgical instrument sterility using short-cycle sterilization for sequential same-day use. Ophthalmology. 2018;125(9):1320-1324.

2. Chang DF, Mamalis N. Guidelines for the cleaning and sterilization of intraocular surgical instruments. J Cataract Refract Surg. 2018;44:765-773.

3. Palmer DJ, Robin AL, McCabe CM, Chang DF; Ophthalmic Instrument Cleaning and Sterilization Task Force. Reducing topical drug waste in ophthalmic surgery: multisociety position paper. J Cataract Refract Surg. 2022;48(9):1073-1077.

4. Wu AM, Kumar P, Stein JD, et al. A videographic evaluation of eyedrop administration by ophthalmic technicians. Ophthalmology. 2021;128(5):796-798.

5. Tauber J, Chinwuba I, Klyn D, et al. Quantification of the costs and potential environmental effects of unused pharmaceutical products in cataract surgery. JAMA Ophthalmol. 2019;137(10):1156-1163.

6. Berkowitz ST, Finn A, Sternberg P, Patel S. Potential cost savings associated with a multiuse preoperative and preinjection eyedrop protocol. Ophthalmology. 2022;129(11):1305-1312.

7. Javitt MJ, Grossman A, Grajewski A, Javitt JC. Association between eliminating water from surgical hand antisepsis at a large ophthalmic surgical hospital and cost. Ophthalmology. 2020;138(4):382-386.

8. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-1398.

9. Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45(9):1226-1233.