August 2020


Survey reveals cataract surgeon, staff attitudes toward OR waste

by Liz Hillman Editorial Co-Director

Studies have already sought to quantify the environmental impact and cost of providing healthcare and its associated waste. Now, a survey of predominantly North American cataract surgeons evaluated their attitudes toward such waste and sustainability as a whole. Overall, the survey found 93% of respondents think the amount of waste produced during ophthalmology’s most common procedure—cataract surgery—is excessive.1
Just one cataract surgery, according to a previously published study from the U.K., can generate carbon emissions similar to driving a car 310 miles.2 In the U.S., a study that looked at unused medical waste associated with cataract surgery from four different sites found 43% of all opened pharmaceuticals went unused.3
In contrast, a study of phacoemulsification at the Aravind Eye Care System in India, which uses mainly disposable supplies (including gloves, gowns, tubing, irrigation bottles, instruments, and pharmaceuticals), found it generates 250 grams of waste per phaco and nearly 6 kg of carbon dioxide-equivalent greenhouse gases.4 That’s 5% of the U.K.’s carbon footprint for the same procedure.
“It’s one thing to have data on the footprint of a surgery and another to understand how that data will be received,” said Cassandra Thiel, PhD, a coauthor of the survey alongside David F. Chang, MD, who wrote the paper on behalf of the Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force. Members of ASCRS, AAO, the Outpatient Ophthalmic Surgery Society, and the Canadian Ophthalmology Society—the four societies represented on the task force—were surveyed. “The survey helps us understand how clinicians think about these topics. What do they want? What would they be comfortable doing? What would they not be comfortable doing? Why? The survey helps us understand where we have existing leverage to make changes and where we have obstacles we would need to overcome in order to make changes.”
Cathleen McCabe, MD, said it’s been stated that surgeons and patients prefer disposable, single-use supplies, but this survey contradicts that statement.
“When 96% of respondents are in agreement that a change is needed, industry and legislative bodies may be compelled to take action. In my experience, waste considerations and carbon footprint are increasingly expressed concerns of my patients as well,” Dr. McCabe said.
The OICS Task Force developed a 23-question survey for cataract surgeons as well as a parallel, nearly identical survey for OR administrators and nurses. The survey was completed in full by more than 1,300 respondents, the majority of whom practiced in the U.S. (86%). Most respondents (70%) had been in practice for at least 10 years and operated in ASCs (61%).
Here is just a sampling of some of the survey’s findings regarding physician and OR staff attitudes on cataract surgery waste and its environmental impact:
• 91% said they were concerned about global warming and climate change.
• 68% think there is “far too much” cataract surgery waste, compared to 5% who think the amount is appropriate for the procedure.
• 79% prefer reusable over disposable instruments, assuming comparable cost.
• 93% of surgeons want more freedom to reuse disposable products at their discretion.
• At least 72% would consider reusing irrigation solutions and tubing, capsulotomy needles, cannulas, metal blades, and nonmetal devices such as iris retractors.
• 87% would like their medical societies to advocate for the reduction of surgical carbon footprint.
Respondents cited regulatory agencies and facility regulations as having the greatest impact on limiting their reuse of supplies, along with other factors like manufacturers’ efforts to reduce liability and driving the market toward more profitable single-use products.
Dr. Chang, who is co-chair of the OICS Task Force, said this survey showed overwhelming support for having more reusable options and for manufacturers’ instructions for use (IFUs) that allow surgeons to decide when it is safe and appropriate to reprocess and reuse a product.
“I was impressed that the majority of respondents are open to reusing most intraocular drugs and many supplies, such as phaco tubing and irrigation solution. I also expected more divergence in opinions between surgeons and nurses. Instead, they were quite closely aligned for most questions, including reuse of many supplies and devices,” Dr. Chang said.
Dr. Thiel said she was surprised by the number of surgeons and nurses who reported already using multidose or reusing specific pharmaceuticals and supplies.
“Infection control is one of the things most often cited (anecdotally) for why we don’t reuse or multidose medical items, and our survey found that a lot of surgeons and nurses are already successfully doing this,” Dr. Thiel said.
With studies that show the potential to reduce waste from cataract surgery without negatively impacting patient safety, what’s next? One might think the next step is to go straight to regulatory agencies, but Drs. Chang, McCabe, and Jeffrey Whitman, MD, agreed that surgical supply manufacturers might be able to have a greater, faster impact.
“The simplest way of changing this is we don’t have to go to lawmakers if [industry] makes changes on their own, and that is to change their IFUs,” Dr. Whitman said. “I think if we get to industry, that’s the easiest way. If we can’t then we do need to talk to politicians to see, governmentally, how we can move this forward.”
Dr. Chang said the survey “sends a clear message to the surgical manufacturing industry that ophthalmologists are concerned about excessive surgical waste and want more reusable products.” Dr. McCabe also said that manufacturers changing their instructions for use would be “one of the most straightforward and rapid changes” to reduce waste.
“Unless there is data to support a risk of reuse—and there has been an enormous volume of surgeries in health systems like the Aravind hospital system that demonstrate safety—there is no reason to write IFUs in a way that limits reuse,” she said, adding that she thinks the survey shows “potential competitive advantage” for manufacturers who address concerns about OR waste and its concomitant environmental impact.
Going forward research-wise, Dr. Thiel said more evidence is needed to show some reuse practices are safe, as well as implementation research to establish guidelines that enable everyone the ability to reuse/reduce waste safely.
Dr. Thiel also sees the opportunity for regulatory change to facilitate reuse/reduced waste practices, and she thinks manufacturers could be developing products with a smaller environmental footprint. Finally, she said education is still important.
“I think it is incumbent on medical schools to teach their students about climate change and sustainability,” Dr. Thiel said. “The COVID pandemic taught us how vulnerable our medical supply chains are, and climate change will only cause more supply shortages. In addition, climate is affecting our patients’ health, and medical trainees should be aware of these issues. In addition, we should start training students and practicing physicians how their own practice causes climate change and other environmental pollutants that negatively affect health.”
Ultimately, Dr. Thiel said the survey offers hope that interest is at least moving in the direction of making medicine more sustainable.
“It’s not going to be easy, but this suggests it’s very possible,” she said.

About the sources

David F. Chang, MD
Clinical professor
University of California,
San Francisco
San Francisco, California

Cathleen McCabe, MD
Medical director
The Eye Associates
Sarasota, Florida

Cassandra Thiel, PhD
Assistant professor
Departments of Population
Health and Ophthalmology
New York University Grossman School of Medicine
New York, New York

Jeffrey Whitman, MD
President, chief surgeon
Key-Whitman Eye Center
Dallas, Texas


1. Chang DF, et al. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46:933–940.
2. Morris DS, et al. The carbon footprint of cataract surgery. Eye. 2013;27:495–501.
3. 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.
4. 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.

Relevant disclosures

: None
McCabe: None
Thiel: None
Whitman: None



Survey reveals cataract surgeon, staff attitudes toward OR waste Survey reveals cataract surgeon, staff attitudes toward OR waste
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