Just as the results of modern ophthalmic surgery are amazing, so too is the amount of waste that surgical procedures generate – in terms of both physical waste and greenhouse gas emissions.
Leaders in ophthalmology – surgeons, distributors, and manufacturers – all have an important role to play in ensuring a sustainable future for the industry.
The recent Australian Federal Election has spurred The Royal Australian and New Zealand College of Ophthalmologists (RANZCO), along with nine other medical colleges, to call all political leaders to commit to ensuring our healthcare system is climate ready and climate friendly.
Due to both high surgical volumes and considerable disposable consumption, cataract surgery is the greatest source of emissions and waste within ophthalmology
Waste from a morning cataract theatre list. Image supplied by RANZCO.
While calling for urgent climate action to protect patients from the consequences of extreme weather events, the open letter also outlined how the medical field wishes to be part of the solution. The signatories were advocating for support to ensure the healthcare system can reduce its own climate footprint.
So, how much of a problem is this climate footprint?
To put it into perspective, the Australian and New Zealand healthcare sector accounts for 10% of national economic activity and contributes around 5% of total greenhouse emissions. That’s more than the aviation industry.1
Due to both high surgical volumes and considerable disposable consumption, cataract surgery is the greatest source of emissions and waste within ophthalmology. The main sources are patient travel, clinic building and energy use, and surgical equipment including sterilisation and waste disposal. A single cataract procedure is equivalent to the energy consumed by the average person during a week.2
In a study to measure the environmental impact of cataract surgery in Wellington, New Zealand, researchers found an average of 151.9kgCO2e of emissions from 142 cataract surgeries, not including perioperative clinic visits. The researchers compared this footprint to that of an economy ticket on a one-hour flight, or combustion of 62L of petrol, that would take 45m2 of forest one year to absorb.1
Another Wellington-based study, which mirrored the method used in the cataract surgery study, looked at the carbon footprint of 226 intravitreal injections across four public injection-only clinics in the Wellington region. Breaking the measurements down into four key areas – travel time for patients and staff, building energy use, waste disposal and procured pharmaceuticals and disposables – the researchers found a combined emissions footprint of 14.1kgCO2e, equivalent to a 6L petrol burn, or 75km drive.3
It’s not something we’re unaware of. In a 2020 survey to ascertain Australian ophthalmologists’ opinions on climate and sustainability, 52% of participants said they strongly believed that climate change due to carbon emissions from human activity is an urgent issue, with 41% strongly agreeing that ophthalmologists should adjust their everyday practice to be more sustainable.4
Results from the Wellington study highlight that “working with industry suppliers is perhaps the most effective first step. Central government policy will create high-level and top-down changes, but changes in the behaviour of individual surgeons will also be required.”1
Faced with these concerning figures, and our awareness of the impact, the eye care industry has reason to be concerned, and such concern should drive change.
INDIA LEADING THE WAY
The Aravind Eye Care System (AECS), a group of eleven speciality eye hospitals in Southern India, is the gold standard of sustainable surgery.
The overall carbon footprint of a phacoemulsification surgery in the AECS is around 6kgCO2e, with around 250 grams of waste created per case (20% plastic face drape, 25% intraocular lens packaging and two-thirds of waste recycled locally).5 This figure is particularly impressive in comparison to results from Cardiff, United Kingdom, which has an estimated footprint of 182kgCO2e.1
Closer to home, pilot data from Rotorua, New Zealand, suggested a footprint of around 122.54kgCO2e – slightly better than United Kingdom figures, though nowhere as low as in India.5
This staggering difference in surgery footprints is attributed to the AECS’s development of an efficient system for delivering high-quality, high-volume and low-cost cataract surgery. A main component of this surgical system is the greater reuse of equipment. In fact, a significant portion of the AECS’s emissions occur in the sterilisation process of reusable instruments. As well as this, the AECS recycles large quantities of waste, uses cheaper locally sourced surgical materials, and has a quick patient throughput and time efficiency of surgeries, which helps reduce building and energy use.
A study into the AECS’s model found that this system can occur because of the domestic manufacturing of supplies, the use of a specialised workforce and standardised protocols, and the presence of few regulatory hurdles.6 Currently, the implementation of the AECS model is not entirely feasible in many countries, including Australia and New Zealand.
However, there are still improvements to be made.
RANZCO’S RESPONSE
In January 2021, RANZCO established a Sustainability Committee, comprising seven ophthalmologists from Australia and New Zealand, to implement the goals set out in the College’s Sustainability Charter.
Associate Professor Michelle Gajus, a member of the RANZCO Sustainability Committee, explained that the Committee is seeking to apply sustainable principles at a personal, hospital and organisation, and global level.
“There is no doubt that we are becoming increasingly concerned for the future of our environment. An increasing proportion of climate change is anthropogenic, and people are recognising that the earth’s resources are finite,” said Assoc/Prof Gajus.
“It’s important that we are good stewards of what we have, and do our best to reduce our harmful impact on our world. As the saying (from the Spiderman movie) goes, ‘With great power comes great responsibility’. The Sustainability Committee is keen to encourage our fellows to practice ophthalmology in a responsible and sustainable manner.
“We chose to concentrate our first efforts on how to reduce the environmental impact of our most commonly performed procedures, such as cataract surgery.”
To tackle this, the Sustainability Committee, in consultation with the Clinical Standards Committee, has produced preferred practice guidelines (PPG) for cataract surgery. This includes initiatives such as the ‘Stop the Drop’ campaign which encourages ophthalmologists to stop using postoperative antibiotic drops.
“Post-operative antibiotic drops have been proven in many studies to be unnecessary. This change alone can save hundreds and thousands of dollars each year, and reduce the development of antibiotic resistance,” said Assoc/Prof Gajus.
This will also help to minimise the amount of topical drug waste produced – which is a big factor in the sustainability of ophthalmic surgery. The authors of a United States-based study estimate that discarded topical eyedrops and ointments from unused or partially used containers generates 23,000 to 105,000 metric tons of unnecessary CO2eq emissions annually in that country.7
On an organisational level, Assoc/Prof Gajus says she has discussed ceasing the use of post-operative drops with her colleagues at the Shellharbour Public Hospital (which performs all public ophthalmology surgery in the Illawarra region of New South Wales), and to great effect.
As well as this, she says her colleague, Dr Mick Loughnan, has been in conversation with Cura Group of Day Hospitals, which are responsible for performing 55% of all private cataract surgery in Australia.
“Dr Loughnan has had great success in ‘greening’ the cataract surgical packs. For example, they will now contain compostable cellulose bowls rather than plastic ones. He is working with management, procurement, nurses and anaesthetists to re-examine how things are done in theatre using the reduce, reuse and recycle principles.
“Mick noted that most of the packs in theatre were made before people had even thought about sustainability, and most people are very supportive of reducing waste once the issue is raised,” Assoc/ Prof Gajus told mivision.
“We see that more and more people are realising that this issue is important, and there is urgency in the need to take action.”
Importantly, RANZCO’s Sustainability Committee has been invited to run a symposium about sustainability at the World Ophthalmology Congress in September, and will be conducting a workshop on decarbonising cataract surgery at the RANZCO Congress in October.
DISTRIBUTOR SOLUTIONS
It is well-known that single-use disposable instruments and equipment in surgery contribute to a mass production of clinical waste. Such waste, along with the energy required to run surgical equipment, contributes significantly to carbon emissions.
In ophthalmology, the commonly used femtosecond laser resides in a separate room to the operating theatre, costs a hospital around AU$70,000 a year in service fees, and requires a temperature regulated environment, whereby the room is thermostatically controlled for the duration of the laser’s use.
A sustainable and cost-effective alternative to this is the Capsulaser, introduced to the Australian and New Zealand market by Device Technologies in 2021.
“The Capsulaser is a compact solid-state laser that performs precise capsulorhexis, a critical aspect of cataract surgery. The system fits conveniently under the existing surgical microscope, eliminating the need for a dedicated temperature-controlled room and gases,” George Loucas, Business Manager at Device Technologies, told mivision.
“By seamlessly integrating into the existing theatre infrastructure, it significantly saves space, increases the efficiency of workflow, reduces ongoing consumables and operating costs, all of which reduce the environmental impact of laser-assisted cataract surgery.”
Also in the realm of cataract surgery, Oertli Instruments, a phaco manufacturer based in Switzerland and distributed locally by Device Technologies, is providing a sustainable solution to single-use cassettes.
“On average there are roughly 300,000 cataract surgeries performed in Australia each year, and that’s 300,000 phaco cassettes being used,” said Mr Loucas. “Our phaco cassette and tubing system are reusable across multiple cases, thus eliminating significant waste associated with single use cassettes and tubing. The packaging is also significantly reduced in size.”
Also on this front, the SOPHI phaco system by This AG, distributed by Designs for Vision, offers surgeons several unique and innovative features that enhance efficiency and safety, while reducing waste and energy consumption.
“One aspect of the use of SOPHI consumables that appeals to hospitals is the sustainability and cost benefits of the ‘day cassette’ option. The SOPHI cassette system may be used for single use (one per case as per other phaco systems), or reused with a new tubing set. This option utilises one cassette for every 10 cases, with replacement tubing per case, which reduces the volume of waste and overall cost of the consumables for the surgery list,” said Harry Gatsoulis, Product Manager – Surgical, Designs for Vision.
SOPHI aligns with the efficiency principles of no wasting of materials, energy, time and storage space, to present a sustainable option for ophthalmologists.
SUSTAINABILITY AT THE MANUFACTURER’S END
Beyond the operating theatre, the big manufacturers are waging their own climate war.
Zeiss, a leader in the manufacturer of surgical devices, recognised, in its 2020/21 Sustainability Report, that “Zeiss’ business activities impact the climate by producing greenhouse gases.” With this acknowledgement, Zeiss has set itself new environmental targets with regard to water, waste, energy and CO2 emissions that it aims to achieve by fiscal year 2024/25.
An example of Zeiss’ sustainability achievements can be seen in the use of photovoltaic systems which convert light to electricity. The largest installation generates around 680,000 kilowatt hours of power every year, equal to the average annual power consumption of around 200 family homes. During the reporting year 2020/21, the company compensated for roughly 46,000 tons of CO2 emissions.
Similarly, Bausch & Lomb measures fuel, energy, water and waste (FEWW) throughout its global operations, with the annual goal to improve at least one FEWW metric by 10% per operations site. To show for these efforts, in 2020, the company reported a significant reduction in the CO2 equivalent generated by global facilities, in comparison to prior years.
Meanwhile, at Alcon Surgical, their Global Environmental Sustainability Strategy has resulted in the successful completion of 40 energysaving projects, which have saved approximately 5,510 metric tons of CO2 equivalent. This includes the implementation of eight LED projects across manufacturing, distribution, and R&D, which resulted in an estimated annual saving of 6,500 gigajoules.
In their 2020 Corporate Responsibility Report, Alcon stated that the company is “committed to conserving natural resources, implementing energy efficiency programs, and reducing our overall carbon footprint” by setting annual targets for waste, water, and energy reduction projects, and monitoring the results of ongoing environmental initiatives.
Johnson & Johnson Vision Care’s commitment to sustainability – broken down into the three main components of climate, waste reduction and natural resources – has also achieved strong results.
On the climate front, this year, 100% of electricity for Johnson & Johnson Vision Care is expected to come from renewable sources – three years ahead of target.
As well as this, a mission to reduce secondary packaging on all Johnson & Johnson Vision Care products has resulted in significant headway in reducing the impact of shipping, distribution, energy, consumption, and greenhouse gas emissions. To quantify this success, the company saves 42,000 tons of CO2 annually through renewable and energy efficient programs.
SUSTAINABLE BENEFITS OF A CIRCULAR ECONOMY
In the product development process, Zeiss has set an environmental goal of ensuring a circular economy by extending the service life of products.
In 2021, the company was awarded the Environmental Technology Award in Baden-Württemberg (Materials Efficiency) for retrofitting – a sustainable process that essentially upgrades, or modernises, a system or machine to adhere to currently applicable occupational health and safety standards. Having existing machines serviced, repaired and refurbished, eliminates the need to produce, transport and install a completely new system or machine, which reduces material consumption, extends a machine’s life cycle and minimises energy consumption.
“We have a team of factory trained engineers across Australia and New Zealand, who are dedicated to install, service, maintain and repair our machine base. Our devices can be upgraded to allow customers to recycle their devices while upgrading to the latest software or technology,” said Rob Wensing, Medical Service Manager at Zeiss.
“We are also a leader in remote support technology, which enables fast response and resolution with minimal transport energy consumption.”
Alcon Surgical has a similar approach. The company’s program to reprocess used or obsolete surgical equipment has positive implications for the environment, by reducing waste, and provides expanded access to surgical equipment in low- and middle-income countries at a lower cost.
In order to extend the life of devices, technical service engineers replace parts and update the existing technology to restore surgical equipment to Alcon’s operational standards. Alcon then uses environmentally safe methods to dispose of any parts that cannot be reprocessed.
In 2020, Alcon refurbished close to 90 metric tons of reused, recycled, and donated equipment and spare parts.
A COMBINED EFFORT
A sustainable healthcare sector relies on the efforts of all industries. For ophthalmology, the considerations made by surgeons, hospitals, distributors, and manufacturers all help to reduce carbon emissions and prevent the needless production of waste.
With the demand for cataract surgery predicted to rise by 50% in the next 20 years (from 2017)8 alone, it’s clear that the efforts outlined above should not only be maintained, but further evolved. Every initiative – on a personal or global level – plays an important role.
References
- Latta M, Shaw C, Gale J. The Carbon Footprint of Cataract Surgery in Wellington, New Zealand Medical Journal, 3 September 2021, Vol 134 No 1541.
- Giannaccare G, Breda JB. For a greener future of ophthalmology. Eye 36, 656-657 (2022). https://doi. org/10.1038/s41433-031-01445-w
- Chandra P, Welch S, Oliver G, Gale J. The Carbon Footprint of Intravitreal Injections, Clinical & Experimental Ophthalmology, Letter to the Editor.
- Gale J, Sandhu SS, Loughnan MS. Australian Ophthalmologists’ Opinions on Climate and Sustainability, Clinical & Experimental Ophthalmology, Letter to the Editor.
- Chandra P, Gale J, Murray N. New Zealand ophthalmologists’ opinions and behaviours on climate, carbon and sustainability. Clin Experiment Ophthalmol. 2020; 1-7. https://doi.org/10.1111/ceo.13727
- Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, Ravindran RD, Thulasiraj RD, Robin AL, Hutton DW, Stein JD. A Sustainable Model For Delivering High- Quality, Efficient Cataract Surgery In Southern India. Health Aff (Millwood). 2016 Oct 1;35(10):1783-1790. doi: 10.1377/ hlthaff.2016.0562. PMID:27702949
- Reducing Topical Drug Waste in Ophthalmic Surgery, Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force and its Surgical Pharmaceutical Waste Subcommittee. https://www.aao.org/clinical-statement/ reducing-topical-drug-waste-in-ophthalmic-surgery
- Wong YL, Noor M, James KL, Aslam TM. Ophthalmology Going Greener: A Narrative Review. Ophthalmol Ther (2021) 10:845-857 https://doi. org/10.1007/s40123-021-00404-8
