Environmental Sustainability in Ophthalmic Plastic and Reconstructive Surgery

Healthcare and climate change are intrinsically linked. Climate change can stress healthcare systems with illness from heat waves, droughts, floods and fires, as well as altering patterns of infectious diseases, influencing air quality and affecting agriculture and the food supply chain.^1,2 On the other hand, strategies to reduce carbon footprint can also have positive health outcomes, such as creating greener living spaces, encouraging eco-friendly dietary consumption, and a shift away from reliance on personal motor vehicles to more active mobility forms. As a further linking of healthcare and climate change, the medical sector itself is a major contributor to greenhouse gas (GHG) emissions, accounting for around 9% of emissions in the United States, where it follows the food industry as the second largest contributor to landfill waste,^1,3,4 and operating rooms are reported to be responsible for approximately 30% of that waste.^5,6

For all these reasons, tackling climate change has been called one of the greatest opportunities for global health.⁷ Despite the opportunity, US healthcare related GHG emissions actually increased between 2010 and 2018.8 However, many health care workers have taken heed and are working to address climate impacts from healthcare.

AAO Task Force and Green Grants

In 2023, the American Academy of Ophthalmology (AAO) formed a task force to make a clear commitment to sustainability,⁹ and in 2024, the AAO offered Green Grants to young ophthalmologists to implement projects that make their practice more sustainable.10 Two American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) candidate members were among the inaugural Green Grant recipients for projects to reduce waste in oculofacial plastic procedures.

Prior to this, the cataract surgeons have led the way with multiple studies evaluating the carbon footprint of cataract surgery across the globe,^11–18 as well as initiatives to reduce topical drug waste,4 re-use instruments/equipment where possible,¹⁹ and converting intraocular lens package inserts to electronic documents.²⁰

Surveys

There have been several surveys of surgeons’ attitudes towards sustainbiilty.^21–23

• The two largest surveys included over 1200 North American cataract surgeons and nurses, and 450 members from European Society of Cataract and Refractive Surgeons:^21,22
• Both found that over 90% of respondents were concerned about climate change.
• 90% felt the amount of waste generated by cataract surgery was excessive and ought to be reduced.
• In 2024, a survey of oculofacial plastic surgeons’ attitudes towards sustainability was conducted with finding of similar results:²⁴
• Over 90% of respondents were concerned about climate change.
• 93% thought there was excessive waste generated during oculoplastic surgery.

Topical Drug Waste

A multi-society position paper⁴ on the drug waste in ophthalmic surgery was released in 2022. The paper was endorsed by the AAO, American Society of Cataract and Refractive Surgeons (ASCRS), American Glaucoma Society (AGS), and Outpatient Ophthalmic Surgery Society (OOSS). Key statements were:

• Drug waste costs an estimated $195,000 annually and generates 23,000 to 105,000 metric tons of unnecessary CO2 equivalent emissions annually in the US.
• Topical drugs in multidose containers can be used on multiple patients if proper guidelines are followed.
• Topical drugs in multidose containers can be used until the manufacturer’s labeled date of expiration.
  • Discarding of partially used bottles after 28 days was a policy adopted by some institutions based on Centers for Medicare & Medicaid Services (CMS)’s regulations surrounding injectable/infusible medication due to an absence of regulations for eye drop bottles.
  • In 2022 CMS confirmed this policy does not apply to eye drop bottles.
• Patients should be allowed to bring their partially used medications home for postoperative use.
  • State regulations vary on this: the AAO has established a Topical Medical Waste Reduction Act link to a legislative template to help assist state societies with advocating for regulatory change to allow this.
  • Typically, the medication should be properly labelled, a non-narcotic medication, and used during their admission.

Reusable Instruments

The Ophthalmic Instrument Cleaning and Sterilization (OICS) task force, comprising specialists representing the AAO, ASCRS, AGS, and OOSS, has published ophthalmology-specific guidelines for surgical instrument processing and sterilization that maximize efficiency and sustainable practices.²⁵

A 2024 study paper evaluated the microbiology of instruments and devices that were re-used for multiple cases at Aravind Eye Hospital:¹⁹

• Microbiological results showed zero bacterial or fungal growth in any of the 3333 cultured samples.
• There were zero cases of endophthalmitis in the 3241 cataract cases observed over 6 weeks.

Greenhouses Gases

In ophthalmology, direct greenhouse gas (GHG) emissions can result from inhaled anesthetic gases as well as procedural use of fluorinated gases, such as in vitreoretinal (VR) surgery.

• Global Warming Potential (GWP) refers to how much heat a greenhouse gas traps in the atmosphere compared to carbon dioxide over a specified unit of time.
• Inhaled anesthetic agents (desflurane, sevoflurane, isoflurane, and nitrous oxide) are all potent greenhouse gases.^26,27
  • Less than 5% of anesthetic gases are metabolized, so ultimately most inhaled anesthetic will be released into the environment.
  • Desflurane and nitric oxide have the highest GWP.
  • Nitric oxide is the gas most responsible for depletion of ozone.
  • Choices made by anesthesia providers can significantly reduce direct atmospheric emissions of healthcare organizations.
• Fluorinated gases include sulfur hexafluoride (SF6), hexafluoroethane (C2F6), and octafluoropropane (C3F8).^28,29
  • Fluorinated gases have atmospheric lifetimes of several thousand years, compared to CO2, which persists for approximately 100 to 300 years, and so their GWP increases significantly with time.

Quantifying Waste From Blepharoplasties

Sustainability in our subspecialty is still nascent and only a few studies have been published to date. Two studies have been published reporting on the environmental impact of blepharoplasty surgery.

• Hu & Rizzuto performed a life cycle assessment of an officed-based blepharoplasty finding it contributed a total of 6.42 kg carbon dioxide equivalents (CO2eq), whereas the same procedure at an ambulatory surgery centered contributed 7.78 kg CO2eq.³⁰

  • For reference, a phacoemulsification in the UK contributes 130 kg CO2eq per eye, compared to 6 kg CO2eq per eye at Aravind Eye Center in India.³¹
• Lee et al.32 compared the waste generated from a bilateral upper lid blepharoplasty done at a hospital-based Ambulatory Surgery Center (ASC) to one performed at a privately-owned ASC and found the hospital-based ASC generated 2.74 kg of waste per blepharoplasty versus 1.43 kg in the private ASC.
  • Carbon emissions were 9.7 kg CO2eq per case at the hospital-based ASC versus 5.0 CO2eq at the privately owned ASC.³²
• In both studies, nonwoven polypropylene was the single material that contributed the greatest weight to waste generated: this would include items such as drapes and gowns.
• Studies looking at safety and feasibility of reduced-area draping, especially for non-sterile procedures such as dacryocystorhinostomy (DCR), are currently underway and given the prior studies, will be an important part of addressing waste in our subspecialty.

Survey Of ASOPRS Members

• A 2024 survey of 79 ASOPRS members showed over 90% were concerned with sustainability.^24</li>
• 93% felt the waste from oculoplastic surgery could be reduced.
• 56% of respondents have already made changes to increase sustainability in their practice.
• Compared to the survey of cataract surgeons, more oculoplastic surgeons were concerned with medication waste and there was a stronger feeling that patients should be able to take medications home with them.
  • There is a multi-society positional paper on multi-dosing of medication in ophthalmology in general, but no specific studies or position papers exist yet for oculoplastics.
  • Allowing patients to take medications is a complex issue bound by state legislations and institutional policies; some states such as Illinois and Colorado have passed legislation allowing properly labeled medications that were used in a procedure to be given to patients to take home, but surgeons must check their local regulations.

Sustainable practices can lead to cost savings, increased efficiency, and organizational resilience. Although studies showing these benefits specifically in oculoplastics have not been reported yet, they have been reported in other areas of medicine.

• A study from Pennsylvania in 2010, documented a savings of $89,000 by proper waste segregation in their operating rooms.³³
• Another from Maryland showed $70,000 savings in switching to reusable sharps containers.³³
• A study by Kaiser Permanente reported $5.7 million and over 200,000 lbs of waste saved by reprocessing single-use items that could be safely cleaned.³³

In ophthalmology specifically:

• Bascom Palmer Eye Institute showed a cost savings of approximately $280,000 per operating room by switching to waterless hand cleaning for their surgery centers.³⁴
• A study evaluating topical drug waste in phacoemulsification showed approximately 50% of all drugs (and two-thirds of topical drugs) were discarded after a single use with an estimated wasted cost of $195,000 annually on unused medication.³⁵
• Multi-dosing could result in a cost-savings of $150 per case in this study.

While many of these factors translate to oculoplastic surgery, studies are needed for our surgeries specifically.

Organizational Resilience and Efficiency

Sustainable choices are generally thought to increase the resilience of an organization, such as to supply chain and other disruptions or extreme events, including pandemics and unsteady political climates.36 For example, it may be more sustainable to source products locally as opposed to internationally, which can be result in delays due to shipping or political disruptions. Another sustainable initiative could reduce the number of in-person post-operative visits, which may increase clinic efficiency. Though logic and theory would suggest these actions are both environmentally sustainable and efficient, more research is needed to support this.

• Sustainability in oculofacial plastics is still nascent but there are many opportunities for research, quality improvement strategies, and cost-savings.
• A survey of ASOPRS members indicated strong interest in this area and support for surgeons making sustainable changes to their practices.
• Areas for future studies to target include:
  • reduced-area draping for non-sterile procedures such as DCR’s
  • safety and efficacy of multi-dosing of medications
  • safety of re-usable instruments in oculoplastics
  • transition to electronic-package inserts for injectables such as botulinum toxin
• As a society, ASOPRS is planning to join Eyesustain, the coalition of ophthalmic societies working together on sustainability efforts, and we hope to see more ASOPRS members awarded AAO Green Grants for sustainability projects.

EyeSustain website: https://www.eyesustain.org/

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