Studies have linked environmental pollution climate change to multiple conditions, including infections from viruses and other pathogens1-4; worsening allergy season duration and severity5-7; damage to nearly every ocular structure8-11; and increasing risk of AMD,12 glaucoma,13 retinal detachment,14 and vascular occlusions.15

The field of retina, with our high surgical and patient volumes, has many opportunities to reduce medical waste. By understanding how the climate crisis is impacting our patients’ ocular and overall health, we can take steps to mitigate the environmental damage our industry causes. I believe we must go even further and join other medical societies in sounding the alarm on this public health emergency.16,17

QUANTIFYING OCULAR SURGICAL WASTE

ORs consume three to six times more energy than any other department in the same facility; they also account for 50% of hospital supply costs and 66% of regulated waste.18 Medical waste from ocular surgery was quantified further by Thiel et al, who showed that a single phacoemulsification performed at Aravind Eye Hospital, India, generated only 3% of the greenhouse gas emissions as did the same surgery performed in the United Kingdom or the United States.19

Moreover, the amount of physical waste generated by these surgeries in wealthy countries was about 7 kg versus about a quarter of a kilogram in India.19,20 Interestingly, the rates of endophthalmitis have been found to be significantly lower at Aravind than in the United States,21 suggesting that surgeries producing higher amounts of waste do not correlate with improved patient safety.

Another study conducted in Dublin quantified the carbon footprint of intravitreal injections and showed that, if unnecessary materials were eliminated, the net savings across the United Kingdom would be approximately 450,000 kg of CO2-equivalents per year.

What Do Ophthalmologists Think?

When asked, ophthalmologists have recognized the unnecessary level of waste that our sight-saving efforts can produce. A 2020 survey of more than 1,300 ophthalmologists conducted by Chang et al showed that 90% were concerned about global warming and climate change, 93% felt OR waste was excessive, 94% felt we should look for ways to reduce waste, and 78% felt we should seek ways to reuse supplies and instruments.22,23

STRATEGIES AND RECOMMENDATIONS

By Albert S. Khouri, MD; Marko Oydanich, MD, MS; and Jasmine Mahajan, BS

No. 1: Analyze the waste. One strategy for reducing OR waste and ophthalmology’s carbon footprint is to separate waste from recyclable material.1

No. 2: Reconsider regulations. Eye care providers, health care administrators, and product manufacturers can reevaluate the benefits and drawbacks of strict regulations on products for which the risks of contamination are not well studied. The theoretical adverse effects of reusing eye drops, gonioscopy lenses, and tonometer prisms are not equivalent to the measurable financial and environmental burden of the waste produced.2 Efforts to reduce environmental costs without sacrificing surgical technique and increasing postoperative complications have shown great promise in several countries, creating an opportunity for a shift in others, including the United States.3

No. 3: Improve education. Studies have found that trainee surgeons generate almost 25% more waste than experienced surgeons. Efforts to reduce greenhouse gas emissions can be augmented through waste reduction education starting at the trainee level.4

No. 4: Conduct research to inform action. There is a dearth of research on the environmental impact of surgical waste in ophthalmology. Studies should be designed to trial different approaches to waste reduction.

This material was adapted from an article that ran in Glaucoma Today, a sister publication of Retina Today. Click here to read the article in full.

1. Buchan JC, Thiel CL, Steyn A, et al. Addressing the environmental sustainability of eye health-care delivery: a scoping review. Lancet Planet Health. 2022;6(6):e524-e534.

2. 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.

3. Namburar S, Pillai M, Varghese G, Thiel C, Robin AL. Waste generated during glaucoma surgery: a comparison of two global facilities. Am J Ophthalmol Case Rep. 2018;12:87-90.

4. Khor HG, Cho I, Lee KRCK, Chieng LL. Waste production from phacoemulsification surgery. J Cataract Refract Surg. 2020;46(2):215-221.

HOW YOU CAN HELP

Fortunately, there are many ways to take action in reducing medical waste and other causes of environmental harm (see Strategies and Recommendations for ideas proposed by a group of ophthalmologists). Consider looking into the below resources to get started:

  • Practice Greenhealth18
  • Healthcare Without Harm24
  • Medical Consortium on Climate and Health25
  • EyeSustain26
  • International Agency for the Prevention of Blindness.27

These resources offer a wealth of actionable, evidence-based guidance on how individual ophthalmologists can get involved. In addition, an excellent recent publication by Sherry et al in Ophthalmology provides concrete steps that eye care professionals can take to address this problem.2

We also have a tremendous ability to educate our colleagues, patients, and the public and advocate for policy changes that can lead to a brighter, more sustainable future for generations to come.

1. Khairallah M, Mahendradas P, Curi A, Khochtali S, Cunningham ET Jr. Emerging viral infections causing anterior uveitis. Ocul Immunol Inflamm. 2019;27(2):219-228.

2. Merle H, Donnio A, Jean-Charles A, et al. Ocular manifestations of emerging arboviruses: Dengue fever, Chikungunya, Zika virus, West Nile virus, and yellow fever. J Fr Ophtalmol. 2018;41(6):e235-e243.

3. Walkden A, Fullwood C, Tan SZ, et al. Association between season, temperature and causative organism in microbial keratitis in the UK. Cornea. 2018;37(12):1555-1560.

4. Boss JD, Sosne G, Tewari A. Ocular dirofilariasis: ophthalmic implication of climate change on vector-borne parasites. Am J Ophthalmol Case Rep. 2017;7:9-10.

5. Anderegg WRL, Abatzoglou JT, Anderegg LDL, Bielory L, Kinney PL, Ziska L. Anthropogenic climate change is worsening North American pollen seasons. Proc Natl Acad Sci U S A. 2021;118(7):e2013284118.

6. Bielory L, Lyons K, Goldberg R. Climate change and allergic disease. Curr Allergy Asthma Rep. 2012;12(6):485-494.

7. Echevarría-Lucas L, Senciales-González JM, Medialdea-Hurtado ME, Rodrigo-Comino J. Impact of climate change on eye diseases and associated economical costs. Int J Environ Res Public Health. 2021;18(13):7197.

8. Johnson GJ. The environment and the eye. Eye (Lond). 2004;18(12):1235-1250.

9. Cullen AP. Ozone depletion and solar ultraviolet radiation: ocular effects, a United Nations environment programme perspective. Eye Contact Lens. 2011;37(4):185-190.

10. Hammond BR, Johnson BA, George ER. Oxidative photodegradation of ocular tissues: Beneficial effects of filtering and exogenous antioxidants. Exp Eye Res. 2014;129:135-150.

11. Adar SD, Klein R, Klein BE, et al. Air Pollution and the microvasculature: a cross-sectional assessment of in vivo retinal images in the population-based multi-ethnic study of atherosclerosis (MESA). PLoS Med. 2010;7(11):e1000372.

12. Chang K, Hsu P, Lin C, et al. Traffic-related air pollutants increase the risk for age-related macular degeneration. J Investig Med. 2019;67:1076-1081.

13. Chua SYL, Khawaja AP, Morgan J, et al. The relationship between ambient atmospheric fine particulate matter (PM2.5) and glaucoma in a large community cohort. IOVS. 2019;60:4915-4923.

14. Auger N, Rhéaume MA, Bilodeau-Bertrand M, Tang T, Kosatsky T. Climate and the eye: case-crossover analysis of retinal detachment after exposure to ambient heat. Environ Res. 2017;157:103-109.

15. Cheng HC, Pan RH, Yeh HJ, et al. Ambient air pollution and the risk of central retinal artery occlusion. Ophthalmology. 2016;123:2603-2609.

16. Atwoli L, Baqui AH, Benfield T, et al. Call for emergency action to limit global temperature increases, restore biodiversity and protect health. BMJ Open. 2021;11(9):e056565.

17. Choi-Schagrin W. Medical journals call climate change the ‘greatest threat to global public health’. New York Times. 2021;9(7). www.nytimes.com/2021/09/07/climate/climate-change-health-threat.html

18. Greening the OR. Practice Greenhealth. Accessed August 30, 2023. bit.ly/45ZPEWN

19. 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.

20. Venkatesh R, van Landingham SW, Khodifad AM, et al. Carbon footprint and cost-effectiveness of cataract surgery. Curr Opin Ophthalmol. 2016;27(1):82-88.

21. Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg. 2012;38(8):1360-1369.

22. 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.

23. Chang DF. Needless waste and the sustainability of cataract surgery. Ophthalmology. 2020;127(12):1600-1602.

24. Healthcare Without Harm. Accessed August 30, 2023. noharm.org

25. The Medical Consortium on Climate & Health. Accessed August 30, 2023. medsocietiesforclimatehealth.org

26. EyeSustain. Accessed August 30, 2023. eyesustain.org

27. Climate Action. The International Agency for the Prevention of Blindness. Accessed August 30, 2023. bit.ly/48s4Uxo

28. Sherry B, Lee S, Brooke S, et al. How ophthalmologists can decarbonize eye care: a review of existing sustainability strategies and steps ophthalmologists can take. Ophthalmology. 2023;130(7):702-714.