The practice of ophthalmology excels at extraordinary treatments and outcomes. It also excels at producing shocking amounts of medical waste — from single-use eyedrops and injectables to single-use surgical devices and accessories. The impact is felt everywhere — from increasing healthcare costs and drug shortages to increasing landfill accumulation and carbon emissions.
However, a growing number of ophthalmologists of all ages are taking a stand and meeting this challenge head on. The three ophthalmologists below offer their own perspectives on a single goal: producing effective changes in clinical practice to reduce medical and drug waste.
Jacob D. Grodsky, MD
PGY-4 Resident
Saint Louis University School of Medicine
YO Info: Why is the reduction of medical waste an important topic for young ophthalmologists?
Dr. Grodsky: Reducing medical waste is such an important topic because it affects our everyday lives as clinicians and surgeons. It’s also an important topic for all generations (and specialities!) within medicine, from medical students all the way up to retiring, senior physicians.
It can be easy to fall into the trap of thinking “that’s just the way it is.” But as young ophthalmologists new to the field, we have a unique perspective and the opportunity to be change-makers by questioning the status quo with the intent of improving our health care system. The easy part is identifying the problem. The hard part is coming up with potential solutions, putting in the effort to explore how to implement those solutions, and being able to stay persistent after hitting roadblocks. And, unfortunately, we live in a world full of regulations and red tape, which are often deterrents to implementing the necessary change.
It’s shocking to look at photos comparing the amount of waste from a single surgery performed in the United States to 10, 20 or even 90 surgeries performed in other less-regulated countries. And while there may be (many) more hoops to jump through here compared to these other countries, it’s important to recognize that we generally still do have the power to implement meaningful changes, and it’s important for young ophthalmologists to step up and make a difference.
Instrument Sterilization
What ways are you making changes to prevent waste in your clinical practice?
Dr. Grodsky: I started getting involved in the process of cost savings and reducing medical waste as a medical student. As anyone who has been in an OR can attest, sterile instrument trays often include many instruments that go unused. These instruments are subsequently resterilized and placed back into the tray. This cycle continues over and over, and there are significant costs associated with this process. Eventually these instruments have to be replaced due to wear and tear, even though they might actually have never been used on a patient.
I was observing in the OR early on in medical school and noticed that the scrub tech would begin each case by removing the same handful of instruments from the tray and placing them on the Mayo stand. I wondered how big of an impact it would make — both in terms of subjective satisfaction and objective costs — if we reduced the number of instruments in that single surgeon’s vitrectomy tray.
I started by meeting with the surgeons and OR staff to identify which instruments were regularly used. I then met with managers and administrators associated with sterile processing as well as the instrument vendors to further understand the standard processes and identify the impact these changes could make. This helped to put together the cost analysis and cost savings data, which I eventually presented to the department. The result was approval to produce a trial run with a new, smaller tray. It ended up being very successful, as it significantly reduced monetary costs, reduced turnover times and increased surgeon and OR staff satisfaction — and is still being used in their OR today.
Multiuse Eye Drops
Dr. Grodsky: Currently, I’m working on a large project related to drug waste in the OR, specifically related to eye drops. At my current institution, like many others, preoperative eye drops are generally used on one patient and then discarded. This adds up quickly. If there are 10 surgeries done in a day and each patient is receiving an anesthetic drop followed by three dilation eye drops, that means 40 plastic bottles of drops are thrown into the garbage at the end of the day. And these bottles are all specifically labeled as “multiuse.”
This is incredibly wasteful. It is not only bad for the environment, but also contributes significantly to the drug shortages that we have all already seen in our short careers. I have been working with the OR and pharmacy administration at my institution to implement a policy change so these eye drops can be used on multiple patients. There’s been red tape to get through, and I’ve learned a lot about specific government drug pricing programs, but we are very close to being successful and launching this new policy.
Nathan L. Scott, MD, MPP
Assistant Professor of Clinical Ophthalmology
Division Chief, Ocular Oncology
Shiley Eye Institute
How is medical waste propelling climate change and impacting your patients?
Dr. Scott: By definition, health care systems are charged with caring for and improving the health of patients. However, we know that our health care system accounts for nearly 10% of all greenhouse gas emissions in the United States. These emissions are linked to escalating global temperatures and rising sea levels, which consequently contribute to severe heat waves, more frequent flooding and many other weather-related incidents that exacerbate various medical conditions (cardiovascular disease, lung disease, allergies, ultraviolet light-related cancers, etc.). They also contribute to increases in hospitalizations and can impede access to care. As such, the U.S. health care system directly contributes to various factors that actually worsen disease.
It is my duty, as a young health care provider, to respond to the increasing data that characterizes our role in contributing to climate change. Immediate action can be taken to address carbon emissions and waste within the healthcare system — and it has the potential to improve the health of our patients on the broadest of levels. Further, the impact of climate change on health disproportionately affects our most vulnerable populations — children, the elderly and those from underserved communities.
Ophthalmology, specifically, has the highest surgical volumes in medicine. Recent studies have shown that the high and escalating volume of intraocular surgery, accompanied by an overwhelming lack of consideration for environmental sustainability, contributes to massive waste and an unnecessarily large impact on the carbon footprint produced by the United States health care system. For instance, it’s been estimated that a single cataract surgery performed via phacoemulsification generated an equivalent amount of carbon dioxide to driving a car 310 miles. Importantly, in India, where many interventions to reduce waste are currently in practice, the carbon dioxide emissions of a single cataract surgery have been calculated to equate to driving a car a mere 14 miles.
It is clear that the current system of unnecessary surgical waste is not sustainable — and more than 90% of ophthalmologists agree that operating room waste is both excessive and concerning according to a recent survey conducted by the Ophthalmic Instrument Cleaning and Sterilization Task Force.
What are some pearls for making impactful change?
Dr. Scott: There are various easy ways to help prevent waste in your clinical practice:
- Educate leadership and staff about the harms associated with climate change as well as the role that we play as medical providers.
- Review your surgical utilization and ensure that only necessary supplies/instruments are being opened/used.
- Explore recycling facilities in your area that are able to recycle medical waste (and divide waste into separate containers accordingly).
- Use available online calculators to determine your facilities’ procedural carbon footprint over time.
- Engage with organizations like My Green Doctor to provide your practice with stepwise programs to “go green” — saving water, energy and ultimately money.
- Support our leaders in both government and the institutions who are committed to taking action to help protect the health of our communities and patients.
Ruth D. Williams, MD
Glaucoma Consultant, Wheaton Eye Clinic
Chief Medical Editor, EyeNet® Magazine
What’s your message to YOs about the role they can play in reducing waste?
Dr. Williams: This topic is important for ALL physicians. But as is often the case with change, it’s our younger colleagues who are driving the change. It’s young ophthalmologists who resonate with the need to address medical waste and who have the hope that we can change the systems that drive waste.
One of our axioms as physicians is to “do no harm.” If, in our work as healers, we contribute to making our planet a less safe environment, then we are harming. We talk a lot about public health issues that impact the health of populations, but we are part of the problem when we unnecessarily generate plastics that end up in the oceans and use materials that require energy to produce.
Many of our single-use materials are used in the name of patient safety, but without the evidence that it makes a difference. It’s our young ophthalmologists who will challenge the systems and ask, “Is there evidence for this regulation?”
How is the Wheaton Eye Clinic making an impact?
Our surgery center is amazingly efficient, and the team has methodically looked at every step in the process to minimize what is used. This process started long before we were thinking about waste as an independent issue. We were thinking about efficiency and cost. The beauty is that minimizing surgical waste, decreasing costs and increasing efficiency are all connected. I argue everyone, even people who aren't interested in (or don't buy) the concerns about climate change, should recognize that addressing surgical waste is simply good practice — it’s good medicine and good business. So, everyone should be on board. Decreasing waste is part of being excellent.
Our surgery center manager empowered every employee to look for ways to decrease surgical waste, and the surgery techs are really proud of how streamlined everything has become. This is an important aspect of any attempt to “green up” a practice or a surgical center — everyone needs to buy into the project. It needs to become a core value. Our employees and even our patients will see things that we get used to because we do it every day.
Most of the work has been done at the surgery center where reducing waste has become part of the culture. Here are a few of the things we've done to decrease waste:
- We use the packaging on the prep tray as the drape over the table. Also, we created our own prep kits consisting of 4-inch by 4-inch wraps and Q-tips in a peel pouch and sterilized in mass quantity. We purchased metal bowls to put in our trays to hold the prepping solution. We use the wrapping from the sterile pack as a barrier for our prep setup. This helped us save money as well as prevented unnecessary waste of a plastic bin and a large wrapping to throw in the garbage for each patient.
- We never throw out sealed packages that are unused from a surgical tray. For example, an unused package of Weck cell sponges is saved, and if a surgeon needs an extra package, it's supplied from our green bin.
- We do not use patient gowns since the patient’s clothing is covered with a facility blanket and then a sterile body drape after being prepped for surgery in the OR. We have recently gone to a half-body drape, which is adequate for ophthalmology procedures.
- Our cataract trays are minimalistic, and all surgeons use the same tray.
- We have reuseable diamond blades on the tray.
For the clinic side, we have a Sustainability Task Force which is just getting started, so there isn't a lot to report, but we are looking at alternative energy for our buildings (we own three of the six locations). This isn't reducing medical waste, but it's working on our overall footprint.
Further Resources
Topical Drugs
Reducing Topical Drug Waste in Ophthalmic Surgery - 2022
This Academy statement recommends that topical drugs in multidose containers can be used on multiple patients if proper guidelines are followed.
Model Legislation
After a bill was passed in Illinois to reduce medical waste, the Academy developed a kit (PDF) to aid in other states' legislative efforts.
EyeSustain.org
The Academy, American Society of Cataract and Refractive Surgery (ASCRS) and European Society of Cataract and Refractive Surgeons (ESCRS) are sponsoring societies of EyeSustain, seeking to collaborate on making ophthalmic care and surgery more sustainable. The Academy also has a task force forming under the leadership of Jeff Pettey, MD, and including Darby Miller, MD, that will be engaging with other young ophthalmologists to network and advance issues of sustainability in ophthalmology.