Ophthalmology Going Greener: A Narrative Review

Sustaining Ophthalmic Practices for the Future: A High-Value Care Approach to Environmental Responsibility

Ophthalmology, like all medical specialities, is continuously evolving to adapt to emerging challenges and advancements. The evidence-based medical practices that previously guided policies and regulations may no longer be sufficient or sustainable in the context of an ageing population, increasing healthcare demands, and the urgent need for sustainability. As the global burden on healthcare systems grows, sustainability must be considered from multiple perspectives, including financial and environmental aspects, without compromising patient outcomes. While financial sustainability is essential to ensure cost-effective resource allocation, accessibility, and affordability for both healthcare providers and patients, environmental sustainability is becoming an increasing priority. Efforts to minimise the carbon footprint associated with medical procedures, transportation, and the production and disposal of ophthalmic equipment and materials are necessary. This paper highlights key examples of areas within ophthalmology where sustainability can be enhanced by practicing high-value care. We describe targeted opportunities that demonstrate how sustainable practices can be successfully integrated into ophthalmology without compromising patient care or operational feasibility.

Patients' perspective on the environmental impact of the severe dry eye disease healthcare pathway

BACKGROUND

The NHS has committed to achieving net-zero carbon emissions by 2045. Dry eye disease, a chronic condition affecting approximately 29.5% of the global population, poses a significant challenge due to its environmentally harmful care pathway, which also exacerbates the condition. This research article presents a multi-centre cross-sectional survey of patients with severe dry eye disease to examine the pollution and emissions associated with the NHS dry eye disease care pathway. The aim is to identify target areas where innovation can aid the NHS in reaching its net-zero goal.

METHODS

Ninety-two patients participated in semi-structured interviews at four tertiary care centres in the United Kingdom.

RESULTS

Medication packaging disposal was reported as follows: 36% of patients disposed of everything in household waste, 13% recycled everything, and 51% used a mixture of both. Only 7% of patients reported that medication packaging had clear recycling instructions, 23% reported no instructions, and 71% had not noticed. Patients attended a median of 3 (range; 1, 15) hospital appointments per year, with 62% traveling by car and a median return journey time of 100 (8, 300) minutes. When asked if having dry eye disease significantly increased their carbon footprint, 32% agreed, 32% were unsure, and 37% disagreed. The predominant suggestion for reducing environmental harm was "environmentally friendly packaging."

CONCLUSION

This research highlights the need for more sustainable packaging solutions, including clearer recycling instructions, and explores issues related to avoidable travel and insufficient education. By addressing these areas, the NHS can make significant progress towards achieving its net-zero emissions goal.

Advancing Sustainability in Ophthalmic Surgeries and Interventions: A Narrative Review of Environmental Impact and Best Practices

Healthcare is a significant contributor to global greenhouse gas (GHG) emissions, and the field of ophthalmology, particularly through high-volume surgeries such as cataract, glaucoma, and retina interventions, has a considerable environmental impact. This review explores the environmental consequences of ophthalmic surgeries, emphasizing recent research on carbon emissions, waste production, and resource use. It also examines current sustainable practices and suggests evidence-based recommendations to mitigate the carbon footprint of ophthalmic care. Sustainability has become a critical priority in healthcare, particularly in high-volume specialties like ophthalmology, which generate significant environmental impact through resource-intensive surgical procedures. This review examines the carbon footprint of key ophthalmic surgeries-cataract, glaucoma, and retina-and identifies primary sources of emissions, including single-use disposables, energy consumption, and the use of potent greenhouse gases such as sulfur hexafluoride (SF₆) in retina surgery. Strategies to mitigate these impacts are proposed, focusing on transitioning to reusable instruments and supplies, reducing pharmaceutical waste, optimizing energy use in surgical facilities, and considering air tamponade as a viable alternative to high global warming potential (GWP) gases in retina procedures. Case studies, such as the sustainable practices at Aravind Eye Hospital, illustrate the feasibility of combining high-quality ophthalmic care with environmental responsibility. By adopting evidence-based solutions, the field of ophthalmology can significantly reduce its ecological footprint, aligning with global sustainability initiatives while maintaining patient safety and surgical efficacy.

Primary Eyecare Glaucoma Service (PEGS): a mixed methods service evaluation

PURPOSE

A pilot study to assess the safety and efficacy of a Primary Eyecare Glaucoma Service (PEGS), with low-risk glaucoma patients being reviewed within primary care optometry.

METHODS

98 low-risk glaucoma patients were identified as suitable for monitoring in primary care and reviewed by accredited optometrists in community practice supported by a clinical management plan. Safety was assessed by reviewing concordance of management plans created by primary care optometrists and the secondary care team. Patients' and primary care optometrists' feedback were collated via surveys. Carbon emissions were calculated through comparison of patient travel to primary and secondary care.

RESULTS

93.8% of patients reviewed by primary care met criteria for ongoing monitoring in primary care after initial review with 4.9% of patients being recalled to secondary care due to clinical instability. Safety and efficacy were demonstrated with agreement of management plans between primary and secondary care of 97.8%, kappa =0.88 (95% confidence intervals 0.60-1.00), with no patients being identified as false negatives where recall back to secondary care was required. Overall satisfaction with PEGS was 100% according to a patient survey. Respondents of the primary care optometry survey felt very or somewhat confident in delivering care, with comments suggesting they felt supported by secondary care. Carbon emissions are reduced by approximately two thirds when patients are seen in primary care versus attending the hospital.

CONCLUSION

PEGS is a safe and effective service, reducing the burden for secondary care, while carbon emissions are reduced due to shorter travelling distances, demonstrating environmental sustainability.

Greener intravitreal injections: a narrative review

Healthcare services are significant contributors to climate change. Ophthalmology, by virtue of the volume of appointments and procedures it generates, is thought to play a major role in this regard. Intravitreal injections (IVI) are a commonly performed ophthalmological procedure to treat patients with conditions such as macular neovascularisation secondary to neovascular age-related macular disease or myopia, diabetic macular oedema, and retinal vein occlusions. As IVIs become more ubiquitous, addressing their environmental impact and sustainability will become increasingly important. Strategies to tackle carbon emissions from IVIs may target the following areas which align with the Greenhouse Gas Protocol scopes: building energy; water consumption; travel to appointments; manufacture and procurement of the drug and other necessary materials; and waste disposal. We propose a path towards a more sustainable approach for IVIs, and discuss its potential safety as well as the patient experience.

Teleophthalmology at a primary and tertiary eye care network from India: environmental and economic impact

OBJECTIVE

To evaluate the environmental and economic impact of teleophthalmological services provided by a primary (rural) and tertiary (urban) eyecare network in India.

METHODS

This prospective study utilised a random sampling method, and administered an environmental and economic impact assessment questionnaire. The study included 324 (primary: 173; tertiary: 151) patients who received teleconsultations from July to September 2022. The primary network (rural) used a colour-coded triage system (Green: eye conditions managed by teleconsult alone; yellow: semi-urgent referral within 1 week to a month, red: urgent referral within a day to a week). The tertiary network (urban) included new and follow-up patients. The environmental impact was assessed by estimating the potential CO2 emissions saved by avoiding travel for various transport modes. Economic impact measured by the potential cost savings from direct (travel) and indirect (food and wages lost) expenses spent by yellow and red referrals (primary) and the first-visit expenses of follow-up (tertiary) patients.

RESULTS

The primary rural network saved 2.89 kg CO2/person and 80 km/person. The tertiary urban network saved 176.6 kg CO2/person and 1666 km/person. The potential cost savings on travel expenses were INR 19,970 (USD 250) for the primary (average: INR 370 (USD 4.6) per patient) and INR 758,870 (USD 9486) for the tertiary network (average: INR 8339 (USD 104) per patient). Indirect cost savings (food and wages) were of INR 29,100 (USD 364) for the primary and INR 347,800 (USD 4347) for the tertiary network.

CONCLUSION

Teleophthalmology offers substantial environmental and economic benefits in rural and urban eyecare systems.

The role of the health sector in tackling climate change: A narrative review

Climate change is one of the largest threats to population health and has already affected the ecosystem, food production, and health and wellbeing of populations all over the world. The healthcare sector is responsible for around 5 % of greenhouse gas emissions worldwide and can play a key role in reducing global warming. This narrative review summarized the information on the role of healthcare systems in addressing climate change and strategies for reducing its negative impact to illustrate different types of actions that can support the ecological transformation of healthcare systems to help reaching sustainable development goals. A wide range of green interventions are shown to be effective to reduce the carbon footprint of healthcare and can have a meaningful impact if implemented systematically. However, these would not suffice unless accompanied by systemic mitigation strategies altering how healthcare is provided and consumed. Sustainable healthcare strategies such as reducing waste and low-value care will have direct benefits for the environment while improving economic and health outcomes. The healthcare sector has a unique opportunity to leverage its position and resources to provide a comprehensive strategy for fighting climate change and improving population health and the environment on which it depends.

Global warming impact of fluorinated gases in ophthalmic surgeries at a tertiary eye center in India

PURPOSE

Global warming is one of the greatest health threats of the 21 st century. The ophthalmic sector contributes to the emission of greenhouse gases, thus altering the natural environment. There is currently no data on global emissions of fluorinated gases in ophthalmic surgery. This retrospective study from 2017 to 2021 aims to report the carbon dioxide (CO 2 ) equivalence of sulfur hexafluoride (SF 6 ), hexafluoroethane (C 2 F 6 ), and octafluoropropane (C 3 F 8 ) at a tertiary eye center.

METHODS

Data collected from 1842 surgical procedures that used injections of fluorinated gases were analyzed. Environmental impact (global warming potential over 100 years) was calculated by converting milliliters to grams by using modified ideal gas law at standard temperature and pressure for the canisters and then to their CO 2 equivalence.

RESULTS

Though 70% of surgeries used C 3 F 8 , the least greenhouse effect causing fluorinated gas, the total carbon emission was 1.4 metric tons. The most common indication was macular hole surgery (36.86%).

CONCLUSION

This study paves a step toward analyzing the problem statement, thus awakening us to contemplate options to make ophthalmic surgeries greener.

Achieving net-zero in the dry eye disease care pathway

Climate change is a threat to human health and wellbeing across the world. In recent years, there has been a surge in awareness of this crisis, leading to many countries and organisations setting "net-zero" targets. This entails minimising carbon emissions and neutralising remaining emissions by removing carbon from the atmosphere. At the 2022 United Nations Climate Change Conference (COP27), commitments to transition away from fossil fuels and augment climate targets were underwhelming. It is therefore imperative for public and private sector organisations to demonstrate successful implementation of net-zero and set a precedent for the global political consensus. As a top 10 world employer, the United Kingdom National Health Service (NHS) has pledged to reach net-zero by 2045. The NHS has already taken positive steps forward, but its scale and complexity as a health system means stakeholders in each of its services must highlight the specifications for further progress. Dry eye disease is a chronic illness with an estimated global prevalence of 29.5% and an environmentally damaging care pathway. Moreover, environmental damage is a known aggravator of dry eye disease. Worldwide management of this illness generates copious amounts of non-recyclable waste, utilises inefficient supply chains and involves recurrent follow-up appointments and prescriptions. By mapping the dry eye disease care pathway to environmental impact, in this review we will highlight seven key areas in which reduced emissions and pollution could be targeted. Examining these approaches for improved environmental sustainability is critical in driving the transformation needed to preserve our health and wellbeing.

Tracing the barriers to decarbonising ophthalmology: A review

As climate change demands increasingly urgent mitigation of greenhouse gas emissions, the health sector needs to do its part to decarbonise. Ophthalmologists share concerns about climate change and seek opportunities to reduce their environmental impact. When measuring the footprint of ophthalmology, major contributions are from patient travel to clinics, and from the large amounts of single-use disposable materials that are consumed during surgeries and sterile procedures. Ophthalmic services in India have already demonstrated systems that consume far fewer of these products through efficient throughput of patients and the safe reuse of many items, while maintaining equivalent safety and quality outcomes. Choosing these low-cost low-emission options would seem obvious, but many ophthalmologists experience barriers that prevent them operating as Indian surgeons do. Understanding these barriers to change is a crucial step in the decarbonisation of ophthalmology and the health sector more broadly.

How Ophthalmologists Can Decarbonize Eye Care: A Review of Existing Sustainability Strategies and Steps Ophthalmologists Can Take

TOPIC

Understanding approaches to sustainability in cataract surgery and their risks and benefits.

CLINICAL RELEVANCE

In the United States, health care is responsible for approximately 8.5% of greenhouse gas (GHG), and cataract surgery is one of the most commonly performed surgical procedures. Ophthalmologists can contribute to reducing GHG emissions, which lead to a steadily increasing list of health concerns ranging from trauma to food instability.

METHODS

We conducted a literature review to identify the benefits and risks of sustainability interventions. We then organized these interventions into a decision tree for use by individual surgeons.

RESULTS

Identified sustainability interventions fall into the domains of advocacy and education, pharmaceuticals, process, and supplies and waste. Existing literature shows certain interventions may be safe, cost-effective, and environmentally friendly. These include dispensing medications at home to patients after surgery, multi-dosing appropriate medications, training staff to properly sort medical waste, reducing the number of supplies used during surgery, and implementing immediate sequential bilateral cataract surgery where clinically appropriate. The literature was lacking on the benefits or risks for some interventions, such as switching specific single-use supplies to reusables or implementing a hub-and-spoke-style operating room setup. Many of the advocacy and education interventions have inadequate literature specific to ophthalmology but are likely to have minimal risks.

CONCLUSIONS

Ophthalmologists can engage in a variety of safe and effective approaches to reduce or eliminate dangerous GHG emissions associated with cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Environmental effects of surgical procedures and strategies for sustainable surgery

There is a bidirectional relationship between climate change and health care. Climate change threatens public health, and health care contributes to climate change. For example, surgery is the most energy-intensive practice in the health-care sector, and gastrointestinal conditions are responsible for a substantial environmental burden. However, environmental costs associated with health care are often overlooked. This issue has been examined more closely in current times. Emerging data are mainly focused on surgery, as the most resource-intensive practice. However, there is still a lack of global awareness and guidance on sustainable surgical practices. This Perspective aims to reassess the evidence on health care and surgery carbon footprints, focusing on gastrointestinal conditions, identify issues that need to be addressed to achieve a more sustainable practice and develop perspectives for future surgical procedures. The proposed framework to mitigate the environmental effects of surgery could be translated to other health-care sectors.

Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol

OBJECTIVE

Calculate the cost savings associated with a multiuse preoperative and preinjection eyedrop protocol.

DESIGN

Economic analysis PARTICIPANTS: Adults undergoing ophthalmic surgical procedures requiring preoperative dilation and intravitreal injections.

METHODS

Economic modeling with scenario analysis was used to derive the value for cost-savings attributable to a protocol where perioperative mydriatic eyedrop bottles are used across multiple patients versus the current protocol where drop bottles are wasted after single patient use. Similar analyses were performed for a multiuse povidone-iodine protocol for intravitreal injections. Sensitivity analyses were used to test baseline model assumptions with varying degrees of waste and patient volume.

RESULTS

The multi-use mydriatic protocol allowed for a 97.1% reduction in the number of eyedrop bottles required for the single-use protocol (1037 bottles vs. 35850 bottles). This led to an estimated five year cost savings of approximately $240,000 (nominal) per institution (performing an average of 1434 cases/year) in the base case. This savings varied minimally in sensitivity analyses accounting for practical limitations (loss, expiration, or contamination) of multi-use containers, with savings of 97.54-95.00% for excess supply ranges from 0%-100% in the multiuse protocol. Likewise, the cost savings varied minimally in sensitivity analyses for eye drop sizes, with savings of 99.23-96.69% for mydriatic eye drop sizes of 15 microliter per drop to 65 microliter per drop, respectively, in the multi-use protocol. Over a five-year period, for povidone-iodine drops prior to performing intravitreal injection, the multi-use protocol required 153 bottles compared to 41,954 bottles (99.6% reduction) for the current single-use protocol, resulting in a nominal cost savings of $41,801, which varied minimally in sensitivity analyses.

CONCLUSIONS

Multiuse perioperative mydriatic eyedrops are a viable option for cost and environmental waste reduction for ophthalmologic procedures and surgeries requiring dilation. Likewise, multiuse povidone-iodine may allow for large relative cost reduction for in office procedures. The total potential savings over five years was estimated greater than $280,000 before adjusting for inflation.