David F. Chang

About David F. Chang

“Global cataract surgical volume has surpassed 30 million cases per year. At this scale, the current level of cataract surgical waste is economically and environmentally unsustainable. Alcon’s next generation phacoemulsification system was a major story in 2025. However, while acknowledging this technological triumph, I believe that the greatest unmet need in phacoemulsification technology is multiuse cassettes that are left in the machine all day. Converting to this model would reduce manufacturing, packaging, and shipping costs, carbon emissions, and non-recyclable plastic waste that ends up in landfills and incinerators. Thanks to production savings, manufacturers could still maintain reasonable margins while reducing facility expenditures, OR turnover time, and shelf storage requirements.

“Unfortunately, there are formidable obstacles to this sensible and necessary paradigm shift. Annual revenues from global cassette sales are $835M USD, with the US and Western Europe disproportionately accounting for 60% of this. Liability concerns surgeons, surgical facilities, manufacturers, and the regulatory agencies that approve commercial devices or oversee OR infection control practices.

“We published three studies in 2025 supporting the safety, benefit, and need for multiuse phaco cassettes. Our survey of APAO members’ OR practices found that reuse (mostly off label) of phaco tubing and cassettes was surprisingly common in many countries (41% of more than 2000 total respondents) (1). With no endophthalmitis data previously published for this common practice, Aravind Haripriya and I reported a rate of only 0.01% in more than 1.1 million consecutive phaco procedures over a 9-year period during which one single-use cassette was routinely reused off label all day (2). Finally, we reported our 1-year data after switching to the only phaco machine with autoclavable cassettes approved in the US (3) For this study, we conducted the first formal life-cycle analysis of a phaco cassette which demonstrated considerable adverse environmental impact when discarded at current scale.

“To summarize these and other studies, I led an EyeSustain task force to write an evidence-based, multisociety position paper calling for industry-wide transition to multiuse phaco cassettes. In a historic first, the American (ASCRS), European (ESCRS), Asia Pacific (APACRS), and Latin American (LATAMSCRS) societies of cataract and refractive surgery co-endorsed this paper, which was published in the February 2026 issue of JCRS (4). Speaking with a unified voice on behalf of cataract surgeons worldwide, the paper called on industry to offer multiuse cassette options for every machine, on regulatory agencies to facilitate review and approval, and on surgeons to reconsider unnecessarily wasteful practices by adopting multiuse options.”

References

1. DF Chang, W See, “APAO survey of cataract surgeons' attitudes toward operating room waste,” Asia Pac J Ophthalmol (Phila), 14: 100243 (2025) Nov-Dec;14(6):100243. PMID: 40915423.

2. DF Chang, A Haripriya, “Postoperative endophthalmitis rate associated with routine off-label reuse of single-use phacoemulsification cassettes in more than 1,000,000 consecutive surgeries,” Asia Pac J Ophthalmol (Phila), 14:100247 (2025). PMID: 41022285.

3. SP Chen et al., “Quantifying the reduction in economic and environmental waste from multi-use phacoemulsification tubing/cassettes and diamond blades,” J Cataract Refract Surg, 52, 124 (2026). PMID: 40922077.

4. DF Chang et al., “Unmet need for multiuse phacoemulsification machine products: multisociety position paper,” J Cataract Refract Surg, 52,117 (2026). PMID: 41250302.