• Current Perspective

    A Greener Path for Ophthalmology

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    Stephen D. McLeod, MD

    By Stephen D. McLeod, MD, CEO


    It is now clear that global inflation has set in as a major issue in the United States and abroad with no easy reso­lution in sight and affecting virtually every sector of the economy. The most recent estimates indicate that health care represents approximately 20% of the U.S. economy; thus, judicious attempts by the health care community to curtail expenses in response to inflationary costs have the potential for substantial impact.

    An obvious first target is expenditures that are deemed wasteful and that do not persuasively contribute to care or safety. Moreover, such waste can have profound environ­mental impact. As pointed out in a recent report prepared by the multispecialty Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force led by David Chang, MD, and its Surgical Pharmaceutical Waste Subcommittee,1 the health care sector is the second largest source of landfill garbage in the United States and generates approximately 9% of total greenhouse gas emissions. Examples abound for us in ophthalmology, from excessive use of disposable instruments rather than sterilization and reuse, to innumerable bottles of topical ophthalmic medications being routinely discarded after single or brief periods of use.

    To be sure, the Academy’s activities to confront the costs and impact of medical waste predate our current economic challenges, and the most recent efforts have largely centered on surgical drug waste. For example, in late 2021 the Acade­my reached out to CMS to highlight policies that contribute to surgical drug waste and to organize an exchange between key staff and ophthalmology leaders to clarify surveyor poli­cies. The focus of the discussions supported by the American Society of Cataract and Refractive Surgery, the American Glaucoma Society, and the Outpatient Ophthalmic Surgery Society was well-defined: policies that result in waste, such as the misapplication of 28-day expiration dates for multidose topical eyedrop bottles, and the mandate to discard multi­dose drops after use for a single patient.

    This joint collaboration by the societies continued with the April release of a position statement,1 which identified three key recommendations assuming adherence to proper guidelines: first, that topical drugs in multidose containers can be used on multiple patients in surgical facilities; second, that topical drugs in multidose containers can be used until the manufacturer’s labeled date of expiration; and finally, that where practical, patients should be able to bring partially used topical medications home for postoperative use. The position statement has now been endorsed by all state oph­thalmological societies.

    These concerted efforts were ultimately successful, and in early June of this year CMS announced changes to ASC surveyor policies clarifying that the 28-day expiration date imposed for injected drugs does not apply to multidose eye­drops. This is a welcome step forward, but tremendous op­portunity remains both in and outside the operating room. This includes improved techniques for handling fluorinated gases, reexamination of sterile packaging and short-cycle sterilization, processes to limit materials needlessly opened and discarded during cases, instrument and supply reuse, and greater efforts to recycle, to name just a few.

    To this end, the Academy has convened a working group led by Jeff Pettey, MD, that is charged with a multifaceted and multidisciplinary effort with three broad goals: to better understand waste and environ­mental impact in ophthalmology, to help us advocate for regulatory support that reduces practice waste and cost, and to help disseminate guidance for best practices to the ophthalmologic community. We recognize that there is a great deal to be learned from the experiences of our colleagues worldwide who practice across a wide range of resource and regulatory environments, and we hope to help to inspire sharing and collaboration to improve both practice and value for all.

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    1 aao.org/clinical-statement/reducing-topical-drug-waste-in-ophthalmic-surgery.