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Think Big, Start Small

As climate change threatens to undermine the last 50 years of gain in public health (1), the widely-known saying, “Actions speak louder than words” seems more pertinent than ever. Shockingly, the health sector could become the fifth largest producer of carbon emissions, globally.

The rates of carbon emissions differ worldwide; my ophthalmology training in India provided insight on the comparison of Indian and UK ophthalmic practices. Where the carbon emissions from a single cataract surgery in the UK equate to driving a petrol car for 500 km, in India this drops to only 25 km. Additionally, a single cataract surgery in the UK creates six times more carbon emissions from disposable instruments compared with India; procurement (instruments, medical equipment, and so on) contribute to 50 percent of carbon emissions (2)

Identifying the problem

In a bid to raise awareness, build consensus, and encourage dialogue among stakeholders (including surgeons, nursing, and administrative staff), we identified the amount of carbon emissions generated from a single cataract surgery at our National Health Service hospital in the UK. Our analysis showed that one cataract surgery generated 121 waste items. Paper and plastics went into mixed recycling and clinical waste bins, the standard cataract tray contained too many instruments, including metal lens injectors, which are not required in every routine case. Many instruments were imported from around the globe, contributing to air miles and, therefore, higher carbon emissions.

After identifying the problem, we sought to find a solution. We created a red, amber, and green approach that stratified all items based on the ease of action ability (green items were easily put into practice, red items were hard to implement).

Realizing the solution

The solution really must begin by asking yourself a simple question: “What can I do?”

Here, I present six small changes you can make in your practice that will contribute to a cleaner planet:

  • Consider swapping single use disposable items, such as gowns, cloth caps, sponge holders, and plastic gully pots for reusable ones.
  • Place disposable metal instruments in specialized sharps bins after use where they are collected and refurbished into non-medical devices, reducing procurement cost and the energy of new metal extraction. 
  • Revise the contents of cataract trays and look at removing any redundant items from your cataract packs. 
  • Invest in high-quality, reusable metal instruments, such as capsulorhexis forceps; they are both cost effective and environmentally sound. 
  • Wash your hands with aqueous alcohol solution instead of antiseptic soap to reduce water usage.
  • Immediate bilateral sequential cataract surgery (using appropriate patient selection) can optimize surgery efficiency by reducing patient travel time and energy waste in air controlled operating rooms.

Ultimately, we propose a modified “RRR” approach as a good place to start in any practice setting. Reduce appointments – as long as there is a standard operating procedure agreed with community optometrists. Reject excess packaging and manufacturers who aren’t transparent about their emissions. Re-use instruments.

Challenges to overcome

Although these small changes are beneficial, there are still large challenges that need to be addressed; for example, reusable phacoemulsification cassettes and tubes. This example calls for innovation, partnering with industry colleagues, and engaging in studies to establish the safety and efficacy of the resulting products. But just because it is hard shouldn’t stop us from trying.

I believe it is essential that we play our part – from the small to the big. Rather than contribute to an unnecessarily high carbon footprint, let’s try to leave behind a greener planet for future generations to enjoy. I’ll end by asking a rhetorical question: Can you make one small change to your practice to make it more sustainable? (The answer is YES!)

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  1. I Tennison et al., “Health care’s response to climate change: a carbon footprint assessment of the NHS in England,” Lancet Planet Health, 5, 84 (2021). PMID: 33581070.
  2. Goel H et al., Improving productivity, costs and environmental impact in International Eye Health Services: using the ‘Eyefficiency’ cataract surgical services auditing tool to assess the value of cataract surgical services. BMJ Open Ophthalmol. 20, 6 (2021). PMID: 34104796
About the Author
Akanksha Bagchi

Akanksha Bagchi is Glaucoma Fellow in the Department of Ophthalmology, Epsom and St Helier University Hospital Trust, London, United Kingdom. She is also a member of the Young Ophthalmologists for Sustainability group (YOFS) for the European Society for Cataract and Refractive Surgery (ESCRS).

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