ASCRS News: EyeSustain Update
Winter 2024
Ophthalmologists aim to deliver high-quality patient care while considering environmental impacts. The healthcare sector, including ophthalmology, significantly contributes to greenhouse gas emissions, partly due to the waste from single-use surgical devices used, for example, during cataract surgery. Adapting our surgical protocols to utilize more reusable devices, improved sterilization techniques, and less physical waste could both environmentally and economically benefit our institutions and profession. Limiting factors when making such changes include the safety and liability of these protocol changes. In this issue’s EyeSustain Update column, Aakriti Shukla, MD, and Rengaraj Venkatesh, MD, discuss the surgical work of ophthalmologists at Aravind Eye Hospital in India. They discuss the results of their standardized protocols that include reusing devices for cataract surgery usually deemed single use in Western countries. Reporting of the work done in India indicates that sustainable practices in ophthalmic surgery can be safely implemented. This approach not only reduces environmental impact but also improves accessibility and affordability of surgeries. The findings suggest a need to reevaluate single-use device regulations, as safety can be maintained with rigorous protocols. Embracing such sustainable practices represents a crucial step toward balancing patient care with environmental responsibility.
Amy Mehta, MD, EyeSustain Update Guest Editor
As ophthalmologists, we strive to provide the highest quality care for our patients, but we must also consider the broader implications of our practices on the environment. The healthcare sector is a significant contributor to greenhouse gas emissions, with operating room waste being a major concern. In ophthalmology, the widespread use of single-use devices and supplies contributes to this waste, raising questions about the sustainability of our practices, particularly in high-volume surgeries such as cataract surgery.
Our recent study, conducted at Aravind Eye Hospital in Pondicherry, India, addresses these concerns by evaluating the safety of reusing surgical materials in cataract surgery.1 The Aravind Eye Care System (AECS) performs more than 300,000 cataract surgeries annually, implementing standardized protocols that include the reuse of multiple surgical devices typically designated for single use in Western nations.2 This practice not only reduces costs, allowing AECS to provide up to 60% of surgeries for free or at minimal cost to low-income patients, but it also significantly lowers the environmental impact of cataract surgery. The carbon footprint of a single phacoemulsification surgery at AECS is merely 5% of that in the U.K.3
To assess the safety of these practices, we conducted a prospective cohort study that involved microbiological cultures of reused cataract surgical devices.1 We divided the devices into three groups: those sterilized using immediate use steam sterilization (IUSS) between cases, those reused without sterilization throughout the day, and residual fluids from balanced salt solution bags used for multiple patients. Our findings were reassuring; none of the 3,333 samples showed bacterial or fungal growth. Moreover, out of 3,241 cataract surgeries conducted using these reused and IUSS-sterilized instruments, there were no cases of postoperative endophthalmitis during the 6-week follow-up period.
These results complement existing data from AECS, where a retrospective study of 2 million consecutive cataract surgeries reported an endophthalmitis rate of 0.04%, comparable to the rate observed in the American Academy of Ophthalmology’s IRIS registry for surgeries performed in the U.S.4,5 This suggests that, with rigorous protocols, the risk of cross-contamination can be minimized, challenging the assumption that single-use mandates are necessary to prevent infections in ophthalmic surgeries.
While it is important to acknowledge that our study focused solely on bacterial and fungal contamination and did not explore viral or prion transmission risks, the absence of microbial growth in reused instruments suggests that sustainable practices may be able to be safely integrated into ophthalmic surgery. This not only has implications for reducing the environmental footprint but also for making surgeries more accessible and affordable globally, especially in resource-limited settings.
The broader application of these findings could pave the way for reevaluating regulations around the reuse of surgical devices in ophthalmology. In many countries, the designation of devices as “single use” often stems from regulatory and liability considerations rather than concrete evidence of increased infection risk. Our study contributes valuable microbiological data to the ongoing dialogue about sustainable surgical practices, emphasizing that safety does not necessarily have to be compromised in the pursuit of environmental responsibility.
The adoption of standardized, sustainable practices in ophthalmology, such as those employed by AECS, represents a significant step toward reducing the environmental impact of high-volume surgeries. It is incumbent upon us as ophthalmologists to continue exploring innovative ways to balance patient care with environmental stewardship, ensuring that our contributions to public health extend beyond the operating room.
About the physicians
Aakriti Garg Shukla, MD
Glaucoma Division, Department of Ophthalmology
Columbia University Irving Medical Center
New York, New York
Rengaraj Venkatesh, MD
Department of Glaucoma
Aravind Eye Hospital
Pondicherry, India
References
- Shukla AG, et al. Reusing surgical materials for cataract surgery: an assessment of potential contamination. J Cataract Refract Surg. 2024;50:993–999.
- Ravindran RD, et al. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg. 2009;35:629–636.
- 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.
- Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45:1226–1233.
- Pershing S, et al. Endophthalmitis after cataract surgery in the United States: a report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology. 2020;127:151–158.
Contact
Shukla: ag2965@cumc.columbia.edu
Venkatesh: venkatesh@aravind.org
