ASCRS News: EyeSustain update
April 2023
by George Liu
Young ophthalmologists’ energy and passion for restoring vision is matched only by their interest in doing so in an environmentally conscious way. Since launching EyeSustain in April 2022, we have had hundreds of ophthalmologists in training and early career practicing ophthalmologists worldwide who have taken an interest in becoming involved. This EyeSustain Update column highlights an essay by George Liu. Mr. Liu was the winner of the 2022 John Henahan Writing Prize for Young Ophthalmologists. This prize is named in honor of John Henahan, who edited EuroTimes, the news magazine of the European Society of Cataract and Refractive Surgeons (ESCRS), from 1996 to 2001. Mr. Liu is a voice for the younger generation of ophthalmologists in his beautifully written response to the prompt, “What can the field of ophthalmology do to meet the pressing challenges of climate change, sustainability, and social equity?”
—Aakriti Garg Shukla, MD, EyeSustain Editor
Our problems, a global issue
The United Kingdom’s National Health Service (NHS) contributes 5% of the country’s carbon footprint. It is not alone. If global health services formed their own country, they would be the fifth-largest carbon emitter on the planet. This is a global issue.
In ophthalmology, patients often present with chronic disorders needing multiple consultations (generating travel emissions), and often, surgical procedures are the only solution. Whilst there is a beneficial high turnover of surgical cases in ophthalmology, this also incurs increased waste generation, which is exacerbated by unsustainable practices such as disposable equipment, including substantial amounts of plastic and iron ore. To make matters worse, an NHS investigation showed that children were being exploited to manufacture surgical equipment in Pakistan. So perhaps reusable sterilized equipment is the way forward? Whilst this appears to be the obvious answer, a study in Chicago, Illinois, showed that the use of ethylene oxide was likely causing higher rates of cancer in residents living near the sterilization factory site. Furthermore, disposable equipment is often significantly cheaper to manufacture compared to reusable equipment, which incurs further sterilization costs. Therefore, how can we safely balance sustainability and public health whilst making surgery financially viable?
Globally, approximately 43 million people are blind. A third of this population is blind due to cataracts—and this figure is set to increase due to the aging population. However, the only definitive treatment for cataracts is surgery. A technique called Life Cycle Analysis (LCA) quantifies the emissions generated across the life cycle of a product in units of carbon dioxide equivalents (CO2e) and can be used to estimate the impact of cataract surgery. The LCA of a cataract surgery is 181.8 kg CO2e, with the greatest portion (54%) generated from the procurement of supplies. This LCA is the equivalent of driving a car for 500 km, a significant carbon footprint.
Similarly, international ophthalmology conferences also have a major carbon footprint. Transport, venue, catering, workshops, and presentations all contribute towards increased carbon emissions. Again, a balance must be established in an effort to maximize education whilst reining in personal interests such as tourism.
The aggregate of these issues contributes significantly to climate change. The effects of pollution, as studied by King’s College London, show that on high pollution days, there are 673 additional out-of-hospital cardiac arrests and hospital admissions for stroke and asthma. If we were to apply these figures to the population of poorer countries, whilst the impact may be the same, their inability to access affordable healthcare generates an international injustice. Therefore, we need to push for global change.
Our solutions, a worldwide effort
Whilst our community may strive for change, we are limited by our lack of actionable data. However, the recent development of applications, such as ‘Eyefficiency,’ encourage research into the environmental impact of cataract surgery by individual surgical units, thus generating the actionable data needed for change.
Variations in the LCA of cataract surgery depend on the surgeon, but there is no correlation between surgical outcomes and environmental cost, as shown in different locations around the world. This suggests that opportunities for more sustainable practice are available without having to sacrifice the quality of care. The Aravind case study showed that cataract surgery was achievable at 5% (23 km by car) of the LCA in the West with no increased risk and significantly reduced waste. However, efforts to pursue a similar case study in the West would be limited by regulations and Western patient perceptions of needing over-personalized care. More recently, the ophthalmic community has increasingly moved to Immediately Sequential Bilateral Cataract Surgery (ISBCS), which has reduced travel emissions that would normally be incurred from a second cataract surgery. Whilst this is a fair improvement, the combination of the Aravind study and ISBCS would provide the most sustainable outcome.
With the boom in technology during the pandemic, healthcare events are more accessible than ever—from the comfort of one’s own home. Therefore, conferences should be hybrid by default, offering in-person attendance for local delegates and virtual attendance for international delegates. For those in attendance, efforts should be made to offset travel-related emissions. Those using renewable energy should be rewarded with reduced registration fees.
In a similar vein, these advances should be utilized in virtual consultations, and other modalities to educate our patients. ‘Ufonia’ artificial intelligence software conducts telephone post-phacoemulsification consultations and greatly reduces anxious patients presenting to Accident and Emergency unnecessarily.
Everything exists in fine balance, and we are currently tipping the scale towards an unsustainable future. We should encourage selflessness and sustainability and change our culture of viewing Earth as an infinite resource. We must grasp these opportunities to stop climate change and accept that evolution may include regression in some aspects of our lives. Our response will determine our survival.
Editors’ note: This essay was the winner of the 2022 ESCRS John Henahan Writing Prize for Young Ophthalmologists addressing the question, “What can the field of ophthalmology do to meet the pressing challenges of climate change, sustainability, and social equity?” It was previously printed in the October 2022 issue of EuroTimes and is being reprinted with permission from ESCRS and EuroTimes at the request of EyeSustain for its column in this issue of EyeWorld.
About the author
George Liu
Medical Student
Anglia Ruskin University School of Medicine
Chelmsford, U.K.
