ASCRS News: EyeSustain Update
September 2023

by Sjoerd Elferink, MD and Shefali Sood, MD

The 2022 publication¹ regarding surgical waste by Chang and Thiel brought to light the perceptions of more than 1,300 cataract surgeons and ophthalmology operating room nurses belonging to the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology, the Outpatient Ophthalmic Surgery Society, and the Canadian Ophthalmological Society. Their responses overwhelmingly demonstrated that surgeons and operating room staff are concerned about global warming and think that surgical waste is excessive and that regulations are overly restrictive. The scope of the survey was limited to North America, and we know that the issue of surgical waste extends globally, primarily in developed nations. A European Society of Cataract and Refractive Surgeons survey² published this year sought to understand the opinions of our European peers. In this EyeSustain Update column, Sjoerd Elferink, MD, and Shefali Sood, MD, review this publication and highlight the similarities and differences among respondents from both surveys. 

–Aakriti Garg Shukla, MD EyeSustain Editor

In 2022, the Dutch healthcare sector accounted for 7.3% of the national climate change footprint and 4.2% of waste generated.³ Almost 5,000 miles away, approximately 10% of greenhouse gas emissions and more than 4 billion pounds of waste in the U.S. were produced by its own healthcare sector.^4,5 A significant portion of healthcare-associated waste (>~70%) is generated from ORs. In 2019, it was estimated that annually, unused pharmaceutical products during cataract surgery generated 23,000 to 105,000 metric tons of unnecessary CO₂ eq emissions in the U.S.⁶

The environmental impact of the waste generated in ORs has not gone unnoticed by ophthalmologists. In a landmark study conducted by the Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force, investigators surveyed the attitudes of cataract surgeons belonging to the American Society of Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology (AAO), the Outpatient Ophthalmic Surgery Society (OSS), and the Canadian Ophthalmology Society (COS) toward OR policies, surgical waste, sustainability, and climate change.¹ Approximately 86% of respondents to this initial survey practiced in North America.

A follow-up study using an identical questionnaire was disseminated to members of the European Society of Cataract and Refractive Surgeons (ESCRS) to investigate consensus in attitudes and foster global alliances among North American and European ophthalmologists.²

Approximately 1,241 ophthalmologists participated in the OICS study and 458 in the ESCRS study. The cohorts were demographically similar; however, while a majority of ESCRS respondents performed cataract surgery in hospitals, a majority of OICS respondents operated in ASCs. Despite differences in practice location, opinions about and behaviors toward surgical waste were similar between the cohorts, demonstrating universal deviations from conventional beliefs about single-use products and traditional operating room policies.

More than 90% of respondents from both cohorts expressed concern about global warming/climate change and thought that surgical waste generated during cataract surgery was excessive. More than 60% of respondents in both cohorts thought that the main drivers of OR waste stemmed from perceived safety benefits of single-use items and that manufacturers: 1) produce these single-use items with packaging creating unnecessary waste, 2) drive the market toward more profitable, single-use products to limit liability, and 3) lack environmental/carbon footprint considerations. One noteworthy difference in opinion between the OICS and ESCRS cohorts was that ESCRS respondents ascribed less impact on surgical waste to hospital/facility policies and regulatory agencies to reuse supplies. Despite this, both OICS and ESCRS respondents advocated for similar global strategies for reducing surgical waste, including regulatory bodies allowing more surgeon discretion in reusing products and that manufacturers consider environmental impact, such as using recycled materials and offering more reusable instruments/supplies.

Single-use instruments are a major cause of surgical waste, and most respondents to both surveys either reuse or are willing to reuse surgical products, pharmaceuticals, and instruments. A minority of respondents thought that patient preference was a major driver of single-use instruments. More ESCRS members were currently reusing intraocular pharmaceuticals like lidocaine, antibiotics, and capsular dye. Of note, more than 20% of ESCRS respondents reused phacoemulsification and I/A tubing and irrigating solution compared to less than 8% of their OICS counterparts. Both OICS and ESCRS participants were interested in eliminating the full-body drape and making use of short cycle autoclave sterilization processes for reusable instruments.

The results of the OICS and ESCRS surveys highlight a global paradigm shift among ophthalmologists toward OR practices promoting sustainability in the context of climate change. The concordant responses from surgeons in these studies call into question the conventionally held premise that surgeons prefer single-use products and historical OR standards and protocols. In fact, many respondents thought we should develop ways to reduce waste and were currently reusing or willing to reuse pharmaceuticals and other OR supplies. Among the OICS group, those working in ASCs were more likely to reuse products, demonstrating that institutional policy may be limiting reuse. Most ESCRS respondents work in hospital settings and still were more likely to reuse items compared to their OICS counterparts. 

Instead of relying on OR protocols intended for general surgery cases, ophthalmologists around the globe are redefining OR standards of care to promote environmental sustainability, efficiency, and high-quality patient outcomes. The Aravind Eye Hospitals in India have adopted sustainable practices and achieved postoperative endophthalmitis rates lower than the U.S. while significantly decreasing the carbon footprint of phacoemulsification.^7,8 In 2022, a multi-society position paper was released by the OICS Task Force demonstrating the safety of: 1) using multidose topical eye drop bottles on multiple patients until expiration date and 2) patients using partially used medication at home for postoperative use. These examples of scientific research and guideline position papers endorsed by multiple ophthalmological societies hint at the outdated nature of current OR protocols and highlight that surgeons can have more discretion over reuse of medications and supplies. 

Given these strong and globally held beliefs, ESCRS, ASCRS, AAO, and many other professional ophthalmological societies have collaborated in the global EyeSustain initiative to spearhead initiatives promoting environmental waste reduction in ophthalmic ORs. A new era of sustainable surgery to confront global climate change is beginning, and ophthalmologists around the world are front and center.

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About the physicians

Sjoerd Elferink, MD
Co-founder
Dutch Working Group on Sustainable Ophthalmology
Flevoziekenhuis 
Amsterdam, Netherlands

Shefali Sood, MD
PGY-1 Ophthalmology Resident
Georgetown University/Washington Hospital Center
Washington, D.C.

References

1. Chang DF, Thiel CL. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46:933–940.
2. Chang DF, et al. Survey of ESCRS members’ attitudes toward operating room waste. J Cataract Refract Surg. 2023;49:341–347.
3. Steenmeijer MA, et al. The environmental impact of the Dutch health-care sector beyond climate change: an input-output analysis. Lancet Planet Health. 2022;6:e949–e957. 
4. Kwakye G, et al. Green surgical practices for health care. Arch Surg. 2011;146:131–136. 
5. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11:e0157014.
6. Tauber J, et al. Quantification of the cost and potential environmental effects of unused pharmaceutical products in cataract surgery. JAMA Ophthalmol. 2019;137:1156–1163. 
7. Thiel CL, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391–1398.
8. Haripriya A, et al. Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery. Br J Ophthalmol. 2023;107:780–785. 

Contact 

Elferink: sjoerd.elferink@gmail.com
Sood: shefalisood12@gmail.com