June 2019


A closer look at eye surgery waste

by Vanessa Caceres EyeWorld Contributing Writer

Getting ready for surgery; single-use disposable custom packs and reusable instrument trays being opened and arranged on the back tables

Leftover bottles of tetracaine will be thrown out after surgery.
Source (all): Cassandra Thiel, PhD

Do you know how much waste your clinic generates during ophthalmic surgery?
A group of researchers at New York University are examining surgical waste within ophthalmology. Even with today’s focus on sustainability and waste reduction, ophthalmic surgery has room for improvement.

Delving into the research

The researchers published two studies related to ophthalmic surgical waste and have a third in progress. Cassandra Thiel, PhD, has examined waste in other specialties, including OB/GYN, orthopedics, and radiology.
In one study, researchers compared waste generated during glaucoma surgery at two facilities, one in the U.S. and another at Aravind Eye Hospital, Madurai, India.1 The waste produced in the glaucoma operating room was weighed and compared. The average waste per trabeculectomy in India was 0.5 kg, compared to an average of 1.4 kg at the U.S. facility (P<0.05). When comparing device surgeries and trabeculectomy with phacoemulsification, the average waste was 0.4 kg in India versus 0.7 kg in the U.S.
Dr. Thiel was the lead author in a second study that focused on waste and lifecycle assessment of phacoemulsification at two tertiary care centers of the Aravind Eye Care System in southern India.2 The observational case series used manual waste audits, purchasing data, and interviews with staff to quantify environmental emissions. They found that Aravind generates 250 grams of waste per phaco and almost 6 kg of carbon dioxide equivalents in greenhouse gases, which is an estimated 5% of the phaco carbon footprint generated in the U.K. but with comparable surgical outcomes. “Surgical systems in most developed countries and in particular their use of materials are unsustainable,” the researchers concluded.
“We produce 20 times the waste they do, yet our outcomes are no better,” said Joel Schuman, MD.
Results from a third study were presented at the 2018 American Academy of Ophthalmology Annual Meeting by Jenna Tauber. The study included four surgical sites and focused on routine phaco cases. They found that many drugs used in cataract surgery were not fully used, leading to an annual waste of $36,900 to up to $195,000 at one center. Eye drops in particular were wasted when compared with ocular injections, such as balanced salt solution and systemic medications. “In many parts of the country, after only a few drops, regulations require that the entire bottle be discarded,” Ms. Tauber said. These results should be published soon.


Contributors to surgical waste in developed countries include single-use products, medications that cannot be reused after opening, packs of equipment that contain materials, and equipment not actually used during surgery, Dr. Schuman said.
Another source is plastic, particularly the draping, gloves, gowns, bowls, and syringes used with every case, Dr. Thiel said.
Waste disposal is also an added cost, Dr. Thiel said. “We don’t have a lot of details on what’s being thrown away and why. Hospitals and surgical centers have to pay not only for purchasing supplies but also for the treatment of various waste streams. This spending on supply procurement and disposal can make up nearly 40% of a hospital’s expenses,” she said. Reducing resource consumption is crucial both for the environment and for the cost of providing care, she explained.
It’s too early to say if there is one particular type of ophthalmic surgery that leads to more waste than others, Dr. Thiel said.
For the most part, a reduction in waste must come from policy changes versus changes by individual surgeons, Dr. Schuman said. “The issue mostly has to do with our systems at administrative levels and highly risk-averse countries,” he said. For instance, at Aravind two beds can be placed in a single OR, but HIPAA and infection control guidelines prevent this in the U.S., Dr. Thiel said. Another example: Many areas in the U.S. have policies against allowing patients to take home antibiotics used in the cataract surgery OR.
Dr. Thiel also discussed the trend toward single-use disposables, which she said add to the environmental burdens by producing more waste and creating more emissions from production. However, “it’s difficult to step back from this, as reusables require the right handling and infrastructure locally,” she said.
Yet there’s one other barrier that currently works against surgical waste reduction.
“I think the biggest limitation is lack of awareness of the issue and a lack of a comprehensive approach to deal with the issue,” Dr. Thiel said. “It requires innovation, and it requires the right range of people around the table.”
Another consideration is the potential harm adopting “greener” policies in the U.S., similar to those used at Aravind, could create, Dr. Schuman said.


There are some steps that ophthalmic surgeons can potentially follow to lower waste.
1. Think minimalist. “Surgeons can limit their requested equipment and medications to only what they truly need and ensure that only what they need gets opened,” Dr. Schuman said.
“If you don’t bring it in to the OR, you don’t have to throw it out—so start there,” Dr. Thiel advised.
2. Recheck policies. “If the institution permits surgeons to send patients home with drops from the OR, they should take advantage of this policy and do so,” Ms. Tauber suggested. If not, surgeons could bring up the issue at departmental meetings.
3. Update policies. Once you’ve examined where to cut down on waste within your own surgery, see if it’s possible to expand that among your peers. This could include the development of an “always needed” surgical list versus an “as needed” list, Dr. Thiel said. She also advised eye surgeons to consider better scheduling, task shifting, and the flow of supplies through the physical space. “Can you get creative while still maintaining safety and effectiveness?” she said.
Dr. Thiel thinks ophthalmic surgery—cataract surgery in particular—has the potential to lead the sustainable surgery movement. “Cataract surgeries are incredibly successful and generally have a lower infectious risk than abdominal or joint surgeries. This gives ophthalmologists more space to explore which policies truly protect patient and staff health and which only give the appearance of protecting patient and staff health,” she said.

About the sources

Joel Schuman, MD
New York University
Langone Eye Center
New York

Jenna Tauber, MD candidate
New York
University School of Medicine New York

Cassandra Thiel, PhD
Assistant professor
Department of Population Health New York University School
of Medicine New York

Contact information

Schuman: joel.schuman@nyulangone.org
Tauber: jenna.tauber@nyulangone.org
Thiel: Cassandra.thiel@nyulangone.org


1. Namburar S, et al. Waste generated during glaucoma surgery: A comparison of two global facilities. Am J Ophthalmol Case Rep. 2018;12:87–90.
2. 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.

Financial interests

: None
Tauber: None
Thiel: None

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