ASCRS News: EyeSustain Update
Winter 2025

by David F. Chang, MD, chair of the EyeSustain Advisory Board

The “reduce, reuse, and recycle” slogan became popular in the 1970s with the passage of the Resource Conservation and Recovery Act. In medicine, it is critical that we are able to safely transition to the reuse and multiuse of items in the most frequency performed procedures. In this EyeSustain Update column, we feature David F. Chang, MD, co-founder and chair of the EyeSustain Advisory Board, discussing the new position paper advocating for multiuse phacoemulsification cassettes. 

Emily Schehlein, MD
EyeSustain Update Guest Editor

The four regional multinational societies of cataract and refractive surgeons have jointly endorsed a position paper¹ on the importance of multiuse phacoemulsification cassettes to safely reduce unnecessary surgical waste and carbon emissions. Identifying this as a major unmet need in cataract surgery, the position paper calls on industry to prioritize development of multiuse supply options for every phacoemulsification machine platform and for regulatory agencies to facilitate review and approval of these products. 

This is the first time that the American Society of Cataract and Refractive Surgery (ASCRS), the European Society of Cataract and Refractive Surgeons (ESCRS), the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), and the Latin American Society of Cataract and Refractive Surgery (LATAMSCRS) have collaborated on a joint position paper—in this case speaking to industry and policy makers with a unified voice on behalf of cataract surgeons worldwide. The paper was developed in conjunction with EyeSustain, a global coalition of 55 ophthalmology societies collaborating to advance sustainability in eyecare through education, research, innovation, and advocacy. 

This position paper is an evidence-based review of the global phacoemulsification cassette market, global survey data on surgeon practices and opinions, and published evidence supporting cassette reuse safety and the impact of this practice on unnecessary carbon emissions and non-recyclable plastic waste. Considering that lens material and irrigation fluid are sterile, there is no evidence that single-use phacoemulsification cassettes are safer compared to reusable cassettes, and many facilities worldwide have been reusing single-use cassettes off-label for years. 

Surveys of cataract surgeons’ practice patterns and attitudes toward operating room (OR) waste have been conducted in North America, Europe, and most recently, Asia Pacific.^2-4 In each survey, more than 90% of ophthalmologists thought that surgical waste is excessive, wanted more reusable supply options from manufacturers, and wanted more discretion from manufacturers and policymakers to reuse certain products. In each survey, approximately 75% of respondents were willing to reuse phacoemulsification tubing/cassettes and unused irrigation solutions. However, there were large regional differences in the percentage of surgeons that were currently reusing these products. Phacoemulsification tubing/cassettes were being reused by 41% of respondents in Asia Pacific, compared to 21% in Europe and 7% in North America.⁴ This presumably reflects geographic differences in regulations governing off-label reuse of single-use supplies.    

As an example, the Aravind Eye Care System’s (AECS) 15 eye hospitals in southern India routinely reuse a single-use phacoemulsification tubing/cassette for the entire surgical day’s caseload of 20–30 procedures. We recently reported that their postoperative endophthalmitis (POE) rate with this protocol was 0.01% in 1,133,959 consecutive phacoemulsification procedures performed during the 9-year period between 2016 and 2024.⁵ This was lower than the 0.06% POE rate in 9,587,018 cataract surgeries from the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) Registry during an overlapping 10-year period from January 2013 to March 2023.⁶ Intracameral moxifloxacin prophylaxis was used in every procedure at AECS during this period, which would not have been true of the IRIS Registry population. However, because of U.S. regulations, virtually all the IRIS Registry cases would have been performed with single-use cassettes. We previously published an AECS microbiological study that cultured tubing reused all day and residual irrigation fluid from bags that were reused on multiple consecutive eyes.⁷ None of the 370 cultures were positive for bacterial growth, consistent with a low risk of cross contamination.

In another recent study, we published a cost and carbon footprint life-cycle analysis of an autoclavable tubing/cassette that is FDA-approved for up to 20 uses.⁸ The carbon footprint of 1,000 single-use cassettes with packaging was 725 kg CO₂eq, which would be equivalent to driving a car 1,764 miles (2,849 km). This would generate 527 lbs (239 kg) of waste, of which 85% is non-recyclable plastic. Incorporating this option for the Compact Intuitiv machine (Johnson & Johnson Vision) at our surgery center during the past year cut the waste and emissions by 20-fold and resulted in a 67% cost savings on tubing/cassettes per year. 

Approved “day” cassettes that are reused for multiple consecutive patients without being removed, cleaned, or autoclaved between cases are available for a few machines in some global markets. However, they are not offered by the largest machine manufacturers accounting for the majority of global market share, and none are currently available in the U.S. Machines with the option of a day cassette approved for multiple consecutive same-day cases include the Rayner Sophi (10 cases), Oertli CataRhex 3 (6 cases), and Zeiss/DORC EVA NEXUS (20 cases). The Geuder Megatron S4 HPS and Ruck Qube Pro platforms limit the consecutive number of hours that the day cassette can be used (6 hours and 16 hours, respectively). In addition to reducing OR turnover time, day cassettes reduce the per case costs of manufacturing the product, the facility shelf space to store the product, and the significant carbon emissions and non-recyclable plastic waste from cataract surgery. Several of these manufacturers plan to seek FDA approval of their day cassette option.

With a global mandate to reduce the healthcare sector’s environmental impact, high volume specialties such as ophthalmology must reduce unnecessary waste and emissions, such as by safely reusing products required for every procedure. Now that we are performing 30 million cataract surgeries/year worldwide, the position paper argues that day cassettes and other multiuse supplies should be offered as an option for every phacoemulsification machine. Because of the significant savings in manufacturing, packaging, and shipping costs, this option should reduce facility costs, improve OR efficiency, and dramatically reduce unnecessary waste without compromising safety. The Compact Intuitiv autoclavable cassette example demonstrates that multiuse options need not financially penalize manufacturers in markets such as the U.S. Finally, the paper educates surgeons and their facilities to consider adopting waste and cost-reducing multiuse phacoemulsification supply options when they are available. 

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References

1. Multiuse Phaco Cassettes. Position paper. www.eyesustain.org/resource-library/position-papers/multiuse-phaco-cassettes.
2. Chang DF, Thiel CL. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46:933–940.     
3. Chang DF, Elferink S, Nuijts RMMA. Survey of ESCRS members’ attitudes toward operating room waste. J Cataract Refract Surg. 2023;49:341–347.
4. Chang DF, See W. APAO survey of cataract surgeons’ attitudes toward operating room waste. Asia Pac J Ophthalmol (Phila). 2025 Sep 5:100243. Online ahead of print. 
5. Chang DF, Haripriya A. Postoperative endophthalmitis rate associated with routine off-label reuse of single use phacoemulsification cassettes in more than 1,000,000 consecutive surgeries. Asia Pac J Ophthalmol. 2025 Sep 27: 100247. Online ahead of print. 
6. Ghoraba HH, Haque E, et al. Incidence of endophthalmitis after cataract surgery in the setting of uveitis and immunosuppressive therapy within the IRIS^® Registry. Ophthalmology. 2025;132:1253–1259.
7. Shukla AG, Chang DF, et al. Reusing surgical materials for cataract surgery: an assessment of potential contamination. J Cataract Refract Surg. 2024;50:993–999.
8. Chen SP, Baveja GB, Chang DF. Quantifying the reduction in economic and environmental waste from multi-use phacoemulsification tubing/cassettes and diamond blades. J Cataract Refract Surg. 2025 Sep 9. Online ahead of print.