ASCRS News: EyeSustain Update
Spring 2025
by Andrew Keyser, BS
Each year, millions of patients across the world have their vision restored by cataract surgery, yet the surgical process also generates significant unnecessary waste. Single-use devices, product packaging, and paper instructions for use (IFU) contribute significantly to the environmental footprint of our most performed surgery. In 2024, the EyeSustain Task Force published a joint position paper with the American Academy of Ophthalmology (AAO), the American Society of Cataract and Refractive Surgery (ASCRS), and the European Society of Cataract and Refractive Surgeons (ESCRS), urging the transition to electronic instructions for use (e-IFU) for materials used in cataract surgery.1
Andrew Keyser, BS, is driving this momentum forward. In this issue’s EyeSustain Update column, he explored his recently published study, “Analysis of intraocular lens packaging weight and waste,” which highlights the differences between packaging waste of various IOLs and their paper or e-IFUs.2 This study reveals the disparities in packaging across different IOL models, identifying key opportunities for reducing waste.
Emily Schehlein, MD,
EyeSustain Update Guest Editor
Cataract surgery plays a critical role in healthcare, with nearly 4 million performed annually in the U.S. alone.3 While this surgical volume brings immense benefits to millions of patients, it also contributes significantly to healthcare-related waste and carbon emissions, at approximately 2.3–3.9 kg of waste per case, or roughly 12,800 metric tons per year.4 As such, there is a growing need to reduce the waste and carbon emissions associated with cataract surgery, particularly from the packaging materials used for IOLs, which are universally discarded after every procedure. Against this background, a new variety of IOL delivery system has emerged, in which the lens is housed in a self-contained injector system, the entirety of which is disposed of after surgery. These “preloaded” IOLs require larger packages to accommodate the increased material involved in this design, but until recently, no published research had characterized how much larger these packages were compared to their non-preloaded counterparts.
A recent study, conducted in 2024 by myself, John Hovanesian, MD, David F. Chang, MD, and Cassandra Thiel, PhD, analyzed the packaging waste generated by a range of preloaded and non-preloaded IOLs available in the U.S.2 Our work produced a first-of-its-kind snapshot of the current state of IOL packaging and found that waste varies significantly among brands and product types; the heaviest package across all models, the Rayner RayOne Spheric, weighed four times as much as the lightest, the Zeiss Lucia. We were able to highlight several areas where improvements could be made to lower the environmental impact of cataract surgery. Materials and components of boxes sourced from Alcon, Johnson & Johnson, Hoya, Rayner, RxSight, and Zeiss showed that the average preloaded IOL package weighs approximately 85 g, while the average non-preloaded package weighs 55 g. Beyond the added waste of the injector system itself, preloaded IOL boxes were larger and heavier than their non-preloaded counterparts to accommodate this extra material, further increasing the amount of waste produced by each preloaded model. If these injector systems were substituted for disposable, preloaded IOL cartridges that could be used with traditional autoclavable metal injectors, both packaging weight and size could be reduced, minimizing waste.
It is our hope that this paper can serve as a benchmark against which ophthalmologists and ophthalmic manufacturers alike may inform themselves of the current landscape of IOL packaging and use these findings to drive further reductions to waste produced in the operating room.
Additionally, many IOL packages included bulky IFU booklets, further increasing the waste associated with these products. These IFUs made up approximately 25% of each package and were not only much larger than the IOLs they were packaged with, but in the case of non-preloaded IOLs, were directly correlated with the size and weight of their boxes. This suggested that in the absence of these physical IFUs, packages could be much smaller, and a significant amount of waste could be eliminated. This view was supported by the fact that of the four lightest packages, three utilized e-IFU, small inserts with QR codes linked to an online version of the complete information, in place of paper copies. Furthermore, in a striking direct comparison, we found that while Alcon’s non-preloaded Clareon Vivity IOL utilized an e-IFU weighing only 4 g and accounting for just 11% of the total package weight, the similar but older AcrySof model, also non-preloaded, included a traditional IFU pamphlet that weighed 39 g and took up a full 50% of the total package’s weight. A recently published position paper from EyeSustain explains in greater detail the benefits of e-IFU and addresses many of the concerns associated with transitioning to them.1
By shifting to e-IFUs and implementing preloaded cartridges in place of injectors, a substantial contribution to mitigating climate change can be made. It is our hope that this paper can serve as a benchmark against which ophthalmologists and ophthalmic manufacturers alike may inform themselves of the current landscape of IOL packaging and use these findings to drive further reductions to waste produced in the operating room.
About the author
Andrew Keyser, BS
Kaiser Permanente Redwood City Medical Center
Redwood City, California
References
- Schehlein EM, et al. Reducing ophthalmic surgical waste through electronic instructions for use: a multisociety position paper. J Cataract Refract Surg. 2024;50:197–200.
- Keyser A, et al. Analysis of intraocular lens packaging weight and waste. J Cataract Refract Surg. 2024;50:1270–1274.
- Rossi T, et al. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmology. 2021;6.
- Karmel M. Reducing waste in cataract surgery. American Academy of Ophthalmology. October 1, 2016. Accessed January 19, 2025. https://www.aao.org/eyenet/article/reducing-waste-in-cataract-surgery.
Contact
Keyser: andrew.keyser@hotmail.com
