The number of Americans with cataracts is expected to double over the next 25 years, from 24.4 million to an estimated 50 million by 2050.1 The environmental impact of those surgeries will be significant; one study estimates the carbon footprint of a single cataract surgery to be similar to the emissions produced by driving a car 310 miles (500 km).2
“Given the high volume of cataract surgeries performed, the field of ophthalmology has the ability to globally reduce waste and carbon emissions from surgery,” says Emily Schehlein, MD, a glaucoma and cataract surgeon at Brighton Vision Center in Brighton, Michigan. “Real changes can be made by individual physician and ASC choices.”
Here’s a look at some simple steps that ophthalmic ambulatory surgery centers (ASCs) can use to become greener.
Save on Energy Use
ASCs can reduce energy consumption by employing the same strategies that a person might use at home, such as replacing traditional light bulbs with energy-saving LED lights, says Cathleen M. McCabe, MD, chief medical officer at Eye Health America and medical director at The Eye Associates, both in Sarasota, Florida. Another simple change she suggests is to set programmable thermostats at the facility. That way temperatures can remain within recommended ranges during work hours, but can rise or fall into expanded ranges on weekends and evenings.
EyeSustain provides resources to help make ophthalmology more sustainable, both economically and environmentally.
Dr. McCabe also recommends having a cooler with paper cups instead of giving patients plastic water bottles after surgery. Taking this a step further, a water cooler that’s hooked directly to a water line eliminates the need for large plastic water jugs.
When upgrading HVAC systems or equipment, purchase products that are Energy Star rated, says Cassandra L. Thiel, PhD, assistant professor at NYU Grossman School of Medicine, Departments of Population Health and Ophthalmology at NYU Langone Health in New York city, and president and CEO of Clinically Sustainable Consulting in Madison, Wisconsin. Dr. Thiel notes that regular maintenance will ensure that these devices work at peak efficiency. She also encourages ASCs to consider automating energy efficiency, from screen savers to occupancy sensors—even in the operating room.
Limit Waste From Surgical Packs
Everything in a surgical pack should be used in at least 80% of cases, Dr. Thiel says. She suggests periodically conducting waste audits to determine which items aren’t being used. “Log items which are consistently unused, and then remove them from your packs,” says Dr. Thiel.
Some electronic medical records systems, such as Epic, have buttons for tracking unused items, but most people just don’t use them, Dr. Thiel notes. She suggests tracking unused items for a week right before reformulating packs or assessing preference cards with individual surgeons.
Unused instruments can be donated to hospital wet labs or charitable organizations, says David J. Palmer, MD, a clinical associate professor in the department of ophthalmology at Northwestern Medicine in Chicago. Unused towels and partly used topical povidone iodine solutions can be donated to veterinarians or wildlife refuge organizations.
Several regional nongovernmental organizations coordinate the sorting, packaging, and distribution of donated medical supplies. Some well-known groups that accept medical supply donations include Medshare, Remedy, Not Just Tourists, Project Cure, and the Alliance for Smiles.
Reuse Instruments
Reusable instruments typically produce fewer greenhouse gases and other emissions when compared to single-use instruments, because extracting raw materials doesn’t have to be done repeatedly, explains Dr. Thiel.
Many items used in cataract surgeries in the United States are single use, but this isn’t the standard worldwide. At Aravind Eye Hospital in India, for example, surgical instruments (including blades, cannulas, and phacoemulsification tubing) as well as gowns, masks, and many other items are reused after sterilization. The rate of endophthalmitis at Aravind is 0.01% (with intracameral moxifloxacin) compared to 0.04% in the United States (where intracameral antibiotics aren’t used in all cases).4,5 “This suggests that if multiuse materials are adequately sterilized, patients aren’t endangered,” Dr. Schehlein says.
If space is an issue, or if you’re struggling to overcome unwarranted fears of safety, consider single-use device (SUD) reprocessing, Dr. Thiel suggests. SUD reprocessing is an FDA-approved process in which a third-party takes SUDs free of charge, cleans and sterilizes them, and can then sell them back to an ASC at a significantly lower rate than an original manufacturer’s price.
Use Multi-Dose Bottles
Reusing medications through multi-dose bottles has an enormous economic and environmental impact by reducing drug waste, says Stephanie P. Chen, MD, a cataract, cornea, and refractive specialist at Altos Eye Physicians in Los Altos, California. A study of unused pharmaceutical products after phacoemulsification surgery found that nearly half of all drugs and two-thirds of topical drugs were discarded after one use, amounting to an estimated annual $195,000 wasted per site on unused medication.6
The Ophthalmic Instrument Cleaning and Sterilization Task Force, comprised of representatives of multiple ophthalmic societies, recommends that surgical facilities reuse topical drugs in multi-dose containers on multiple patients and allow patients to take home their partially used medication for postoperative use.7
If prescribing topical drops, be aware that the bottle tips often dispense too much fluid for the surface of the eye to absorb, Dr. Thiel says. Consider products such as the Nanodropper that can reduce this waste and save money for patients. Another option might be to get appropriately sized bottles.
Eliminate Unnecessary Clothing
Consider policies and education on the appropriate use of gloves and personal protective equipment. “After the pandemic, health care workers tended to default to overusing these items,” Dr. Thiel says. “Set protocols for when and when not to use this equipment.”
ASCs should also consider eliminating the habit of having patients change into hospital gowns prior to surgery, because there isn’t any proven benefit to this practice,8 Dr. Chen points out.
Employ Recycling Initiatives
Recycling is the least effective way to reduce carbon emissions, but it can be very engaging for a facility. “Conduct a detailed waste audit prior to implementing a recycling initiative, to see if you can tighten your waste sorting practices and to determine how much recyclable material you actually generate,” Dr. Thiel says. Then, find a regional vendor who can recycle a majority of what the ASC produces, such as aluminum, paper/cardboard, metals, glass, and some plastics.
You may need specialty vendors for items such as blue plastic wrap—or you could move to hard containers for sterile reprocessing and forgo blue wrap entirely, she suggests.
“Recycling requires a lot of mental load from participants, so make it as easy and intuitive as possible,” Dr. Thiel continues. Place bins for easy use, and choose the right sizes for the products being recycled. Use clear signage and consider having special training sessions for staff.
Getting Staff Buy-In
Now that you’re armed with lots of ways to go green, you will want to get staff on board. “Communication should focus on the variety of benefits to staff and your community,” Dr. Thiel says. “Different employees will care about different things—some care about the monetary savings, some care about the planet, while others care about their patients. Sustainability initiatives touch on all these issues.”
Incentivize participation in these initiatives in some way. “Tie sustainability performance into a promotion or bonuses,” Dr. Thiel says. “You could create a revolving ‘green fund’ to help financially support these efforts. Or, if money can’t be used to incentivize performance, find other ways to recognize employees who contribute to your sustainability journey. For individuals who are actively engaged, consider offering protected time to do this work. Show that your organization highly values these efforts, and that the initiative isn’t just another thing that everyone must do in addition to their already demanding jobs.”
Dr. McCabe recommends naming a sustainability officer who can look for opportunities to go green and get other staff members on board.
The main barriers to sustainable practices at ASCs are a lack of knowledge and awareness, as well as regulations—not a lack of interest in promoting them, Dr. Schehlein says. In fact, a 2020 survey found that 93% of cataract surgeons and nurses believe that cataract surgery waste is excessive and should be reduced.9
Major eye societies, such as the American Academy of Ophthalmology (via the AAO Committee on Sustainability), the American Society of Cataract and Refractive Surgeons (ASCRS), and the European Society of Cataract and Refractive Surgeons (ESCRS), are committed to providing sustainable education to their members, says Dr. Schehlein, who is also an editorial board member of EyeSustain. A collaborative effort to prioritize and organize information and ideas on sustainability, the Eyesustain.org website was launched in April 2022 at the ASCRS meeting. EyeSustain provides information on its website and is creating an operating room toolkit that ASCs can use to help reduce waste.
EyeSustain created a simple seven-point surgical facility pledge, which is a symbolic statement that an ASC will try to reduce unnecessary waste, costs, and environmental impact. “By signing the pledge online and having an ASC publicly listed on the EyeSustain Pledge Wall, an ASC can set an example that will hopefully spur others to do the same,” says David F. Chang, MD, medical director of the Peninsula Eye Surgery Center in Mountain View, California, and chair of the EyeSustain advisory board. OASC
References
1. National Eye Institute. NEI charts a clearer future for cataract prevention and treatment. June 29, 2017. Accessed March 20, 2024. https://www.nei.nih.gov/about/news-and-events/news/nei-charts-clearer-future-cataract-prevention-and-treatment
2. Morris DS, Wright T, Somner JE, Connor A. The carbon footprint of cataract surgery. Eye (Lond). 2013;27(4):495-501. doi:10.1038/eye.2013.9
3. Schehlein EM, Hovanesian J, Shukla AG, Rostov AT, Findl O, Chang DF. Reducing ophthalmic surgical waste through electronic instructions for use—a multisociety position paper. J Cataract Refract Surg. 2024;50(3):197-200. doi:10.1097/j.jcrs.0000000000001381
4. Pershing S, Lum F, Hsu S, et al. Endophthalmitis after cataract surgery in the United States: a report from the intelligent research in Sight Registry, 2013-2017. Ophthalmology. 2020;127(2):151-158. doi:10.1016/j.ophtha.2019.08.026
5. 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. doi:10.1016/j.jcrs.2019.04.018.
6. 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
7. 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. Cataract Refract Surg. 2022;48(9):1073-1077. doi:10.1097/j.jcrs.0000000000000975
8. Chang, David F. Tackling the challenge of needless surgical waste in ophthalmology. J Cataract Refract Surg. 2023; 49(4):333-338. doi:10.1097/j.jcrs.0000000000001175
9. Chang DF, Thiel CL; Ophthalmic Instrument Cleaning and Sterilization Task Force. 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
