Standpoint on Sustainability (SOS): Chris Lim

In this latest installment of our SOS series, Singapore-based cornea, refractive and ocular surface surgeon, and Ophthalmology Sustainability lead for the National University Health System cluster, Chris Lim, looks at some of the key challenges of implementing sustainability in the country.

What are the most urgent sustainability priorities in the field right?
 

For environmental sustainability, the main challenge involves getting everyone on board with the program through awareness and education. Many of my colleagues are shocked when they learn that the global healthcare sector is responsible for at least as much carbon emissions as the aviation industry. Once they’ve realized there is an urgent need to answer this call to action, attempts at gleaning information are often marred by misinformation and made worse by apocalyptic messaging with exaggerated and inaccurate predictions that undermine the important and crucial work undertaken by climate scientists. There is a whole heap of resources available out there, but it is increasingly challenging to separate the wheat from the chaff – I know this because I was once a climate skeptic, and it wasn't that difficult to believe some of the arguments if you’re only privy to piecemeal information.

Specific to healthcare and our profession, most ophthalmic practices are by nature high in patient volume. This translates to the potential to generate a significant amount of waste, which may arise from a heavy reliance on single-use instruments and on diagnostic and therapeutic equipment that is energy-inefficient. The charge to minimize waste is crucial for all of us in the healthcare sector as we're called upon to be good stewards of our environment.

The direct impact of our prescribing and use of ophthalmic devices on our patients’ health is an under-explored issue. There has been increasing concern around the identification of contaminants, such as micro and nanoplastics and additive chemicals such as per- and polyfluoroalkyl substances (PFAS). Taking PFAS as an example, the US Environmental Protection Agency has been gradually lowering the permissible safety levels of contaminants, such as PFAS in drinking water. They have now declared that there is no safe level of exposure to these contaminants, which is an alarming development. Yet the use of PFAS in the manufacture of medical devices is neither prohibited nor regulated. A 2023 consumer study demonstrated the presence of organo-fluorine in all tested contact lenses – a surrogate marker for PFAS. There is so much that we do not know about the impact of such exposure on ophthalmic and human health. We urgently need robust and reliable independent data to guide prescribing and patient education within our practice.

Lastly, we need to be vigilant against greenwashing, both through our actions and that of institutions and interactions with industry partners. Deliberate or unwitting endorsement of such behavior may have long-lasting consequences on efforts to develop and grow a community of practice focused on sustainability.

What has changed in terms of how practitioners and the industry have addressed sustainability in the last decade?
 

There has certainly been an increased focus on sustainability over the past decade. Much of the seminal work in the ophthalmic space has been pursued by giants such as David Chang, Clinical Professor at the University of California, San Francisco, USA, who has led the charge and laid the foundation for many of the efforts that we see globally. Through some of this work there is growing awareness amongst practitioners, who are in turn more discerning when it comes to evidence- versus eminence-based medicine. We have started to revisit some of the assumptions that are deeply embedded in our everyday practice, where many of these decisions have been driven by consensus guidelines rather than an evidence-based approach. These include the use of single-use eye drops pre-operatively and a heavy reliance on disposable surgical items.

There has also been an increased focus on sustainability by industry as a corporate social responsibility goal. This has been driven in part by mandatory disclosure requirements by governments, such as the Corporate Sustainability Reporting Directive (CSRD) passed by the European Parliament and the EU Council at the end of 2022. Other countries like Singapore are also gradually phasing in full climate-related disclosures from 2025. This has led to mostly positive change by industry partners, in updating manufacturing processes with the focus of reducing CO2 greenhouse gas emissions. For instance, industry colleagues are reducing the amount of packaging waste that accompanies products. Instructions for use (IFUs) package inserts have gone online and are accessible via QR codes along with increased consideration in the use of sustainable materials in packaging. There are still companies that have yet to adopt such measures however, and are bucking the trend with large single-use plastic devices such as preloaded intraocular lenses.

Sustainability is a topic that seems ubiquitous at events and meetings. But how genuinely is ophthalmology invested in it?
 

Although sustainability now features in most ophthalmic conferences, there is a self-selection bias, where individuals interested in or advocating for sustainability are likely to attend, while others that are either skeptical or disinterested may not see the value in these sessions. Sustainability advocates and champions in the healthcare setting certainly need to be prepared to experience pushback from colleagues across all ranks, who may be very comfortable with their current modus operandi (“what works for me”) and resistant to change.

Can we realistically achieve a truly global buy-in to the sustainability mindset?
 

There are constraints to the adoption of sustainability. In some settings, a focus on sustainability is seen as a privilege – healthcare staff are drowning and buckling under their patient load and sustainability concerns are sometimes perceived as frivolous. Others have written this off as a luxury that only exists in developed nations.

However, there are situations where a simple change can lead to cost savings, and more efficient and effective care of patients. Waterless surgical hand-rubs are one such example. Its adoption in our institution has facilitated cost savings in avoiding use of sterile surgical hand towels and water – a precious commodity in the Singaporean context and in many other countries – as well as shortened time spent on proper hand disinfection between patients. These benefits were achieved while improving patient safety, as waterless antiseptic hand scrubs have been shown to be more effective at disinfection compared to water-based antiseptic surgical hand scrubs which remain the standard of care in most centers.

The sustainability mindset will only work if it is adopted as a way of life. Encouragingly, it has taken center stage and will likely increase in prominence across various sectors. The main question being whether this can be achieved fast enough to fulfill the Paris Agreement’s ideal goal of limiting temperature increases to 1.5°C above pre-industrial levels. Work published in Nature Climate Change has estimated that the remaining carbon budget will be depleted in six years if current levels of CO2 emissions are maintained.

Chris Lim is a cornea, refractive, and ocular surface surgeon based at the National University Hospital in Singapore. There, he leads the National University Health System Ophthalmology cluster’s sustainability initiatives, where his research team are particularly interested in the impact of microplastics and nanoplastics in medical devices on human health. He is also a clinical adjunct assistant professor with the Center for Sustainable Medicine, which is part of the National University of Singapore’s Yong Loo Lin School of Medicine.