Ophthalmology has the highest procedural volumes in medicine, making it a major contributor to health care waste.¹ “But this also gives ophthalmology the unique opportunity to make health care more environmentally and economically sustainable,” observes Aakriti Garg Shukla, MD, an assistant professor of ophthalmology at Columbia University Irving Medical Center in New York city.

Dr. Shukla—who performs cataract surgery, minimally invasive glaucoma surgery, and conventional glaucoma surgery—estimates that at least 20 percent of the items in her surgical pack are wasted. Among the most common items left unused at the end of surgery are cellulose sponges, extra blue towels, tubes of viscoelastic, syringes, and various options for irrigation and aspiration, such as phaco tips.

Cassandra L. Thiel, PhD, is an assistant professor in the departments of population health and ophthalmology at NYU Langone Health in New York city. While observing surgical cases, Dr. Thiel has also seen many unused items get thrown out consistently. These include operating room towels, gauze, syringes, and basins. Sometimes items are tossed after very little use, such as multidose eye drop bottles that are still mostly full. Dr. Thiel founded a company, Clinically Sustainable Consulting LLC in New York city, that focuses on reducing surgical waste.

Examine Your Pack for Waste

Periodically, an ASC should examine its surgical packs to determine whether surgeons are using the items that are included. Multiple approaches can be employed to review packs, depending on the time available and the staff needed to take part in the assessment.

One approach, according to David J. Palmer, MD, a clinical associate professor in the department of ophthalmology at Northwestern Medicine in Chicago, is to conduct periodic “waste audits,” during which the ASC director, head ophthalmology OR nurse, scrub nurses, circulators, and central surgical supply personnel track and examine pack usage. The department chair and operating room oversight team should study the results. Surgeons in a particular subspecialty who use the instruments can then make pack modifications based on a consensus.

Another option, a quantitative approach, involves collecting all items unused after surgical cases, Dr. Thiel says. The survey of unused items could be ongoing or conducted over a set time period. A spreadsheet could be used to keep track of unused items after each procedure.

Whatever approach is used, surgical pack composition should be examined on a regular basis. This could be monthly, quarterly, or annually, depending on local factors such as staff turnover, the purchase of new equipment, and available resources. “Technologies and staff change over time; it’s good to reassess material use consistently to make sure things are running efficiently,” Dr. Thiel says.

Create More Sustainable Packs

Custom packs are not only convenient and efficient, they can also reduce labor costs and potential concerns related to instrument sterilization. But to achieve these benefits, custom packs need to provide the supplies required by most surgeons, most of the time, Dr. Thiel maintains. Although there aren’t any firm rules, an 80/20 estimate is often applied. This means that whatever is in the custom pack should be used in 80 percent of cases. The rest should be available as “pick” items, as needed.

One way to prevent unnecessary waste is to try to create supply standards for all surgeons in the same facility. For example, at Aravind Eye Center in India, surgeons use the exact same instruments in a very standardized approach.² “This standardization prevents one surgeon from using half a custom pack, and another from using two for the same type of procedure,” Dr. Thiel says.

Along with standardization, ASCs and other surgical practices should look toward reducing or optimizing supplies. “The most environmental savings one can garner is by not producing a supply item,” Dr. Thiel says. “So determine what is actually needed for surgeries and don’t allow custom packs to be thoughtlessly added to.”

Finally, replace supplies with more environmentally friendly items when possible. Switching to reusable items is often better for the environment, especially when it comes to greenhouse gas emissions. This includes single-use devices that may be salvaged or repurposed by a third party. Product options made with recycled content, bio-based materials, or compostable materials may also be available. These are better for the environment, Dr. Thiel says, because they decrease extraction of nonrenewable materials and increase circularity of materials.

Dr. Palmer recommends encouraging industry to limit excess materials and supplies. For example, some companies have begun using QR codes instead of printed directions for IOL packages, which can reduce a carton’s size and weight by up to 50 percent. Additionally, he suggests avoiding petroleum-based blue wraps and other nondegradable materials.

Other solutions to reduce waste include incorporating reusable instruments to prevent repurchasing; rethinking packaging strategies with recyclable or biodegradable materials, such as bamboo; using alcohol-based scrub solutions to save water; and working with industry to make drapes, towels, and gowns without petroleum-based materials, Dr. Palmer says. Staff members can also study the slimmed-down pack protocols at other surgical facilities to implement at their own ASCs.

Make Use of Leftovers

Despite surgeons’ best efforts to minimize waste in their packs, some supplies still won’t be used at the end of a procedure. However, rather than throwing them in the trash, ASCs can donate them to charitable organizations that are seeking medical supplies. Many regional non-governmental organizations can handle sorting, packaging, and distributing supplies to regions that need them. “This is probably the best approach, ethically speaking, as they have relationships with the groups to whom they are donating, so they know the local needs and won’t just send supplies to other countries where they may end up as unused trash,” Dr. Thiel says.

Some well-known groups that accept medical supply donations include Medshare in Decatur, Georgia (www.med-eq.org  or www.medshare.org ); Remedy in New Haven, Connecticut (www.remedyinc.org ); Not Just Tourists in Orange, California (www.njt.net ); Project Cure in Centennial, Colorado (www.projectcure.org ); and the Alliance for Smiles in San Francisco (www.allianceforsmiles.org ).

Dr. Shukla has donated unused opened items to wet labs for residents and fellows to use for practice, while Dr. Thiel says some hospitals or departments use unwanted items for art projects such as murals and quilts.

Dr. Shukla’s surgical center allows patients to take home eye drops and ointments they receive in the operating room. Unfortunately, many ASCs do not have a similar policy.

Reduce Medication Waste

Medication represents a significant source of health care waste. Supply procurement is the greatest generator of greenhouse gases in cataract surgery (54 percent); this includes emissions associated with the production, consumption, and disposal of all goods and services consumed during cataract procedures. Medication production, delivery, and disposal comprises 20 percent of all procurement emissions.³

State laws that regulate pharmacy practices, ASC policies, or even a facility’s inability to apply a proper label may prevent patients taking home their partly used, topically applied operating room eye drops that could otherwise be used for postoperative care, says Dr. Palmer. For example, studies show that only 25 percent to 40 percent of OR medications are allowed to go home with patients.^4-6 And a recent survey of OOSS member ASCs found that although most were using multidose bottles to provide medication to multiple patients, only 12 percent continued utilizing the bottles until the labeled expiration date. Nine percent of ASCs discarded the unexpired medication at the end of the surgical day, 3 percent at the end of the week, and 72 percent at the end of the month.⁷

One way to deter medication waste in these instances is to submit a resolution to the state medical society, which ultimately could become a state law. Dr. Palmer did this in Illinois; his resolution was passed by the Illinois General Assembly in 2021 as Public Act 102-0155. The law requires hospitals and ASCs to offer a patient any unused medication upon discharge when it is required for continuing treatment. The American Academy of Ophthalmology (AAO) developed a template based on this law for other states to emulate.

At Northwestern Medicine, working with the pharmacy and IT teams in collaboration with EMR personnel, Dr. Palmer is beta testing a workable and streamlined solution that covers preset orders of medications to proper pharmacy labeling for postoperative dispensing.

Additionally, facilities may save costs and reduce greenhouse gases by using multidose topical perioperative dilating, anesthetic, and glaucoma drops, for example, on multiple patients if applied per CDC guidelines and if properly stored, Dr. Palmer says. Exceptions are containers labeled for single use, and certain non-preserved medications or antibiotic drops.

Unfortunately, a number of states don’t allow eye drop multidosing, which may require modifying their pharmacy practice acts or facility policies to prevent this. In states that do allow multidosing, ASCs have a drop instillation protocol in place approved by accreditation organizations such as the Joint Commission and the American Society of Ophthalmic Registered Nurses (ASORN). It can be found on the website EyeSustain.org , Dr. Palmer says. The ASC administrative staff educates all new perioperative personnel on the protocol, designates a certain area within the facility to safely store the medications, and conducts refresher courses annually.

Other Perks to Eliminating Waste

There are countless benefits to reducing waste, from monetary savings for the ASC to decreasing the environmental impact of cataract surgery.

If a surgical pack is substantially reduced in size, this can save on storage space and associated costs, decrease occupational risks for staff handling the packs, and make stocking the operating room easier with fewer or lighter things to transport. “With happier, healthier staff, there could be gains in terms of retention and turnover,” Dr. Thiel says.

Greenhouse gases and particulates are generated from the manufacture and transportation of every instrument placed on a surgical tray—from procurement to operating room use, to sterilization, to disposal in landfills or the incinerator, to instrument replacement or repair—in addition to the procedure itself, Dr. Palmer says.

Monetary and health costs add up over time as tens of thousands of tons of greenhouse gases are emitted annually. These gases can cause health issues such as asthma or other pulmonary problems, cardiovascular disease, mental health issues, glaucoma, keratitis, conjunctivitis, dry eyes, and macular degeneration, Dr. Palmer says. As health suffers so does the strain on the medical system, driving up costs further.

Added waste also results in increased costs to dispose of them in landfills, where liquid medications may leak into water supplies. Furthermore, the incineration of plastics and other materials may emit cancer-causing toxins, Dr. Palmer says. He recommends limiting the incineration of blue wraps, gowns, and drapes, as these petroleum-based, polypropylene products often contain plasticizers, such as phthalates (DHEP) and bisphenol-A (BPA), that release toxic gases when burned.

More waste adds stress to supply chains to obtain raw materials, produce products, and deliver materials to facilities. Interrupting these steps may lead to surgical scheduling delays and supply shortages, especially if instruments are single-use, Dr. Palmer says.

For more information on sustainability in ophthalmology nationally and globally, visit the website for EyeSustain, a collaboration of the AAO, ASCRS, and the European Society of Cataract and Refractive Surgery (ESCRS). The site contains hundreds of resources on operating room sustainability, some specific to ophthalmic operating rooms, from peer-reviewed publications to lists of action items to improve practices. ■

REFERENCES:

1. Javitt JC, Kendix M, Tielsch JM, et al. Geographic variation in utilization of cataract surgery. Med Care. 1995;33(1):90-105. doi:10.1097/00005650-199501000-00008
2. Rangan VK, Thulasiraj RD. Making sight affordable (innovations case narrative: the Aravind eye care system. Innovations: Technology, Governance, Globalization. 2007; 2(4):35-49.
3. Morris DS, Wright T, Sommer JEA, Connor A. The carbon footprint of cataract surgery. Eye (Lond). 2013;27:495-501. doi:10.1038/eye.2013.9
4. Chang DF, Thiel CL. Survey of cataract surgeons and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46(7):933-940. doi:10.1097/j.jcrs.0000000000000267
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6. Palmer DJ, Robin AL, McCabe CM, Chang DF. Reducing topical drug waste in ophthalmic surgery: multi-society position paper. J Cataract Refract Surg. 2022;48:1073-1077. doi:10.1097/j.jcrs.0000000000000975
7. Ophthalmic Organizations Release Position Statement on Multidose Topical Medications for Ophthalmic Surgery. American Society of Cataract and Refractive Surgery. Accessed March 22, 2023. https://ascrs.org/advocacy/regulatory/guidelines/topical-drug-waste 
8. Tauber J, Chinwuba I, Kleyn D, Rothschild M, Kahn J, Thiel CL. Quantification of the cost and potential environmental effects of unused pharmaceutical products in cataract surgery. JAMA Ophthalmol. 2019;137(10):1156-1163. doi:10.1001/jamaophthalmol.2019.2901