The Green Brigade

Thiel notes that her research into more sustainable ways of working started in a developing region of the world – Southern India, to be precise. “The Aravind Eye Care System… was able to conduct phacoemulsification with only 5% of the greenhouse gas emissions of the UK,” Thiel says. This insight led Thiel and her team to create Eyefficiency, a tool which allows surgical teams worldwide to benchmark and monitor their productivity, costs, carbon emissions, and waste generation during cataract surgery.

In Ireland, John Doris, President of the Irish College of Ophthalmologists (ICO), detailed how the ICO’s annual conference included ophthalmology trainee Emilile Mahon relaying the findings of her research into the ecological impact of phacoemulsification cataract surgery. 

Meanwhile, in Asia, Chris Lim – a cornea, refractive, and ocular surface surgeon based at the National University Hospital in Singapore – oversees the National University Health System Ophthalmology cluster’s sustainability initiatives. Lim and his team are particularly interested in the health impact of microplastics and nanoplastics in medical devices. 

“The direct impact of our prescribing and use of ophthalmic devices on our patients’ health is an under-explored issue,” Lim says. “There has been increasing concern around the identification of contaminants, such as micro and nanoplastics and additive chemicals, such as per- and polyfluoroalkyl substances (PFAS)... Yet the use of PFAS in the manufacture of medical devices is neither prohibited nor regulated.” He adds, “There is so much that we do not know about the impact of such exposure on ophthalmic and human health. We urgently need robust and reliable independent data to guide prescribing and patient education within our practice.”

John Hovanesian, a cataract and cornea specialist at Harvard Eye Associates in southern California, and Assistant Clinical Professor at the UCLA Jules Stein Eye Institute,also points to Avarind as an example of a system that “wastes a small fraction of what we do in the US. He adds that Avarind has “demonstrated, through literally millions of surgeries, that their methods are just as safe – at least from a standpoint of postoperative endophthalmitis – as surgery in the US.” 

The Aravind Eye Care example also spurred David Chang to co-found EyeSustain, a global coalition dedicated to reducing the environmental impact of ophthalmic care. Cataract surgeons at Avarind have “continually analyzed what supplies can safely be reused, and this has produced a large amount of data that can guide all of us to safely reduce waste,” he says. It’s precisely this type of action that is helping bring international attention to the excessive waste generated in the US.

A term coined by Jay Westerveld back in 1986 to convey the hypocrisy he observed at a sprawling Fiji hotel where guests were asked to reuse their towels to help save the environment – all while the hotel was causing ecological damage by expanding its real estate interests – “greenwashing” has since become a regular term. It is commonly used to disparage a company’s ostensible sustainable practices as insincere marketing strategies. Certainly within ophthalmology there are companies paying lip service to sustainability (using buzzwords like “plastic neutrality ”and “carbon neutral manufacturing") without actually following through on their claims. 

“We need to be vigilant against greenwashing” says Chris Lim, warning that “deliberate or unwitting endorsement of such behavior may have long-lasting consequences on efforts to develop and grow a community of practice focused on sustainability.”

Francesco Carones, Medical Director and Physician CEO at Advalia Vision in Milan, Italy, also laments how “eco-sustainability has [now] become fashionable, but the reality is that still not enough is being done in practice.” Radhika Rampat, founder and co-chair of the AECOS (American European Congress of Ophthalmic Surgery) Green Working Group (GWG), agrees: “We talk about it a lot on podiums,” she says, “but the actions haven’t really trickled down to the actual hospitals or clinics in a meaningful way… and the mountains of waste continue!”

However, there is another side to this debate: “Greenwashing seems to be an increasingly easy accusation to make, without offering effective and achievable alternatives,” explains David Lockington, Consultant Ophthalmologist at the Tennent Institute of Ophthalmology, NHS Greater Glasgow and Clyde, Scotland, UK. “We need to remember that taking a small number (surgical footprint) and multiplying it by a big number (number of procedures) ends up with an even bigger number. Ophthalmology does an enormous quantity of high-impact procedures worldwide, so the numbers get big. But it should be considered in the context of the real-world benefits of enabling many patients to get back to work and contributing meaningfully to society.”

The question should be, “How can we deliver more efficiently with less waste?” says Lockington. “We would do well to understand that effective worldwide solutions require a united, global response. Outlawing print programs and conference bags is not going to save a world which groans under an enormous ongoing carbon footprint from the continual atrocities and destructive nature of wars.”

In a practice that is highly dependent on single-use instruments, sterile packaging, and energy-intensive technology, integrating sustainability into ophthalmology can present unique challenges. But “the primary challenge we face in ophthalmology is simply to start and take that first step!” says Andrés Benatti, a renowned cornea and refractive surgeon and LASIK specialist based in Córdoba, Argentina. Benatti believes his colleagues face “five fundamental fears when considering converting their ophthalmology practice into a sustainable one: 1) It doesn’t pertain to my business. 2) I have to overhaul the entire operation. 3) It requires too much effort. 4) The timing isn't right in my country. 5) I don't see an economic benefit.” To combat this reluctance and have ophthalmologists overcome these five fears, Benatti adds, “it’s crucial to spread sustainability measures that are accessible to everyone, from sole ophthalmologists to large ophthalmology centers.”

Ben LaHood, a cataract and refractive surgeon at Adelaide Eye and Laser Centre, and a consultant ophthalmologist at The Queen Elizabeth Hospital, Adelaide, Australia, says that “the most urgent challenge we have to overcome right now is apathy. We are all guilty of this to some degree, me included.” He continues: “We’re all busy, stressed, overcommitted, prioritizing patient care, trying miserably to have a work-life balance, and hoping to run profitable businesses and pay staff wages. To wedge another concern into that mix – one that provides no obvious immediate benefits, is potentially expensive, and takes up more precious mental bandwidth – is a challenge.”

For Chris Lim, the main challenge is around awareness and education. “Many of my colleagues are shocked when they learn that the global healthcare sector is responsible for at least as much carbon emissions as the aviation industry. Once they’ve realized there is an urgent need to answer this call to action, attempts at gleaning information are often marred by misinformation and made worse by apocalyptic messaging… There is a whole heap of resources available out there, but it is increasingly challenging to separate the wheat from the chaff.”

“Over the past decade we have continued to create a garbage-bag full of waste for every cataract operation, but at least now we know it is possible to do better,” says LaHood. “We are starting to see Industry recognize that there is a groundswell of surgeons demanding that it does better. As that voice gets louder, more agile companies make positive changes and market pressure drives the big players to join in.”

EyeSustain lists seven main things that ophthalmic surgeons can do to reduce waste. Co-founder David Chang says: “Everyone should urge their surgical facility to take our online pledge to consider improvements, such as using multidose topical drugs on multiple patients, monitoring custom packs to eliminate infrequently used components, and using alcohol-based hand scrub between cases. These measures reduce costs and waste.”

Chang believes that “industry must prioritize and provide us with more multi-use products, devices, and drugs”, and that “regulatory bodies should not mandate single use of every ophthalmic product by default” when there’s no clear evidence that re-using a product is dangerous for a patient. “The World Health Organization (WHO) has declared that the climate crisis poses the single greatest threat to global public health. Regardless of our subspecialty, we are all physicians, and this should alarm and motivate us all.”

Marius de Beer, Chief Sustainability Officer at HOYA Vision Care, says that “the most urgent sustainability priorities include reducing carbon emissions, managing water footprint, working on creating sustainable packaging solutions, and ensuring that quality eye care for all is a basic human right.” He adds that “sustainability is about creating value, driving growth, and delivering long-term benefits for all stakeholders in our industry, from patients of different ages to our customers and the planet. It is not a temporary trend or a buzzword – it’s here to stay.”

Meanwhile, Barbara Erny, Adjunct Clinical Associate Professor of Pulmonary, Allergy & Critical Care Medicine at Stanford University, believes education is a vital component for having clinicians incorporate sustainability into their practices. “I would also like to see the global development of programs to recycle medical plastics (Australia and India are examples of countries with such facilities),” she says. “And I'd like every physician to understand the connection between plastic waste and human health, as well as how climate change is detrimental to both ocular and general health… I want to see every physician prioritizing the ‘First, do no harm’ principle by practicing in a sustainable way.”

“We need to stop wasting so many resources and just get moving,” says Cassandra Thiel. “Some of the changes are practice changes and some of them are policy changes. Manufacturers also need to focus on changes like creating circularity with their products and reducing wasted items. Initiatives with other stakeholders – such as governments and standards-setting bodies – should also be considered to enable and support medical practices becoming more resource-efficient.”

“The principles of ‘reduce, reuse, recycle’ sound great, but what is the reality?” asks David Lockington. “It all depends on the financial climate, restraints, and incentives of the systems in which we currently live and work… We really need to disrupt the whole system to institute a new prioritization of these principles, from clinicians to industry to government, to deliver high-quality care which is also better for eyes, economics and our environment.”

Chris Lim notes that the sustainability mindset will only work if it is adopted as a way of life. “The main question being whether this can be achieved fast enough to fulfill the Paris Agreement’s ideal goal of limiting temperature increases to 1.5°C above pre-industrial levels.”

“My simple wish,” adds Ben LaHood, “is that individual surgeons begin to ask questions of their own practices, their industry partners, and their colleagues about what tiny things they could do to improve sustainability.”

It may seem idealistic – and perhaps unrealistic to some – but with respected ophthalmic visionaries such as Ben LaHood, Cassandra Thiel, and David Chang leading the sustainability charge, and with non-profits such as EyeSustain being set up as a global coordinated effort to increase awareness, the momentum towards sustainability is gaining traction. This momentum, coupled with institutions like the Aravind Eye Care System proving that sustainability can indeed be incorporated into eye hospitals in a practical and efficient manner, suggests we may be closer to achieving true sustainability in ophthalmology than one might have previously imagined.