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Waste Not, Want Not

There is a clear desire for increased sustainability within ophthalmology. The Ophthalmic Instrument Cleaning and Sterilization Task Force, in a collaborative effort of the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the Outpatient Ophthalmic Surgery Society, conducted a survey of 1300 cataract surgeons and nurses and found that 93 percent believed operating room waste is excessive and needs to be reduced (1). In the US, a single cataract surgery generates as much waste as a typical person generates in an entire week of their daily activities. Across the country, we perform close to 4 million cataract surgeries per year. If you take the collective waste produced in all of those procedures, it is equivalent to the total waste generated by an individual person across their entire lifetime… if their lifetime lasted 66,000 years. This is already a staggering amount of waste to generate before you remember that that’s in the US alone, and just a fraction of the world’s cataract surgery waste. Although we are not likely to eliminate all of it, there are several wasteful practices that can be addressed. In the same way that we collaborate with industry to bring care to patients, we must collaborate if we want to reach our goals of reducing waste and increasing sustainability.

It is no secret that industry has disposables to sell, whether that be phaco needles that are discarded after each case – a practice we know to be unnecessary – cassettes or other disposable elements. There are definitely some disposable tools whose temporary nature genuinely benefits us. In the past, we used steel irrigation and aspiration tips, but with extended use they carried an increased risk of sustaining damage and developing irregularities that could cause complications such as capsule tearing. These were replaced by disposable silicone tips, which are soft and very consistent between cases, reducing the number of capsules torn during cataract surgery. Examples like this demonstrate that there are indeed some instances where we can justify throwing away temporary, small, and inexpensive temporary parts. However, we currently discard far more than this with each case, throwing away larger and more valuable equipment in a manner that is not particularly cost- or environmentally effective.

So what role does industry have to play in this? Naturally, companies want to sell products and that, at face value, creates a conflict of interest, as what we’re aiming to do is reduce the volume of products discarded, which in turn means fewer products being sold. However, we have started off by approaching the larger companies in the field to begin a dialog, figuring out how we might be able to start reducing waste. I firmly believe that as we progress, industry will find meaningful ways to save the environment without having to sacrifice their bottom line.

One example of this is the “directions for use” that come packaged with IOLs. Previous regulations stated that this documentation had to be in every box. It was a large, folded piece of paper that contained many specifics in multiple languages. The truth is that nobody ever looked at it and automatically threw it away, along with the box, which had to be larger, increasing shipping costs. It had a real ripple effect on the manufacturing process and led to more waste. Everyone in our industry agreed that a QR code printed on the box or packaging, linking to the directions of use, would be a sensible way to mitigate this. Slowly, all IOL manufacturers are moving toward this more stramlined standard, allowing us to use less packaging and, as a result, because they are not charging any less for the IOL, increase their profit margin.

Green manufacturing

Similarly, a number of companies are moving to a green manufacturing process, becoming carbon-neutral globally. The goal is to make a meaningful environmental impact in a way that is “invisible” to the end user – the surgeon, nurses, and operating room staff. This takes some effort and does incur some initial costs but, in the end, it saves these companies money. Additionally, it’s highly motivating for the workforce to know that they work for a company which is interested in sustainability.

However, there are many obstacles that industry faces in the move towards sustainability. We have all heard someone tell us that it’s in our best interest to throw away material after every case because if we don’t, we will face penalization by a regulatory body. We don’t always know which regulatory body that may be or whom to contact to even dispel such myths. This is something that’s true for both companies and surgery centers. What we’re trying to do, through the combined efforts of volunteers, is demystify the field. A necessary part of this is working with regulatory bodies, although the effectiveness of this can sometimes come down to the specific person within the regulatory body, their views, and their willingness to support what we are doing.

Companies also have to go through similar processes to implement change. As bigger companies tend to operate in more countries, they have to navigate more regulatory environments, are usually under greater scrutiny, and subject to facing greater penalties than smaller companies, meaning that they have to be more careful. On the other hand, they can have a far greater impact as, for a bigger player, a small change can truly add up, which is a great motivator for taking action. Some of the bigger companies have made changes to their evaluation process for prospective products, meaning that alongside factors such as a product’s efficacy or sales projections, sustainability will be taken into consideration. This is again a seemingly small change, but the future benefit of this could be immense.

Sustaining eye care

As part of EyeSustain, a new, multi-society sponsored sustainability group, we want to celebrate and recognize various achievements and efforts. At the ASCRS meeting in Washington, DC, when EyeSustain was launched under the leadership of David Chang, we held a session where we heard from a number of large and smaller companies about sustainability initiatives and efforts that each is making. The larger companies are not necessarily far ahead of their smaller counterparts in this area. Both groups are making dramatic changes, such as decreasing their packaging, saving energy, recycling in the manufacturing process or allowing products to be reused. It was encouraging to hear of the many initiatives that are being undertaken in the field, and it was truly an opportunity for those who attended to celebrate the successes of their compatriots.

There is no competition when it comes to sustainability; we’re all in it together. Companies can and should learn from each other, and EyeSustain is definitely seeking to help with such efforts. In the future, we hope to have standards in place so that companies can periodically be assessed on the effectiveness of their sustainability efforts to earn accreditation as a sign that their efforts are sincere and effective.

There is good evidence that when it comes to sustainability, profits do not have to suffer. While it may seem initially that sustainability incurs costs, reducing waste will be good for all of us – patients, medical practitioners, and industry professionals – and our individual goals in the long run. Nobody wants to benefit or make money by damaging the environment. While it could be easy for companies to look away and decide that only their bottom line matters, they have already demonstrated more altruistic motives. Companies are recognizing the importance of sustainability and its scope and are rising to meet that challenge. We really are just at the beginning. We have reached a point where the consumer is acutely aware of the problems of climate change and global waste and recognizes the need for true change. People have already shown that they will be willing to spend money on sustainability in the same way that they do for other factors of importance, such as safety and efficacy, making sustainability worthwhile for everyone touched by the procedures we perform.

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  1. DF Chang et al., “Survey of cataract surgeons’ and nurses’ attitudes towards operating room waste,” J Cataract Refract Surg, 46, 933 (2020). PMID: 32773547.
About the Author
John Hovanesian

Specialist in cataract, refractive and corneal surgery at Harvard Eye Associates, Laguna Hills California and Clinical Faculty at UCLA Stein Eye Institute, California, USA

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