Biosimilars

COVID-19

Cataract Surgery

Cataract

Cataract Therapeutics

Clinical Diagnosis

Cornea

Dry Eye Awareness

Dry Eye

Gene Therapy

Geographic Atrophy

IOL Advances

Imaging

Glaucoma Awareness

Glaucoma Insights

Therapeutic Glaucoma

Interventional Glaucoma

Ocular Allergy

Ocular Surface Disease

Optic Relief

Optometry

Pediatrics

Pharmacy

Indispensable

Practice Management

Presbyopia

Ptosis

Refractive Surgery

Refractive

Retina

Surgery

Technology

Therapeutics

Understanding Antibiotic Resistance

Workplace

News

All News

Contributors

Money Matters

Media

Expert Interviews

Medical World News

Podcasts

Case Based Roundtable Series

Case of the Quarter

EyeView

Grand Rounds

Insights

Rapid Readout

Viewpoints

What’s Your WhEYE?

Conferences

Conference Coverage

Conference Listing

Events

Publications

Digital Edition

Europe Ophthalmology Times

Modern Retina

Supplements and Featured Publications

Partners

Subscribe

Resources

Job Board

About

Advertise

Privacy

Editorial

Terms and Conditions

Contact Us

Do Not Sell My Personal Information

Ophthalmology Times - Ophthalmology news, articles, and events

Facebook

Instagram

LinkedIn

Spotlight

Clinical

Glaucoma

1rem

Authors

Removing drops from procedure increases adherence and comfort for most patients.

Dropless cataract surgery: Shifting paradigm in postoperative care

A recurring feature at the 2024 American Society of Cataract and Refractive Surgery (ASCRS) Annual Meeting in Boston, Massachusetts, was the call for environmentally friendly practices worldwide, with the goal of decreasing the impact of ophthalmic surgeries on the planet.

A driving force in this movement is EyeSustain

 an organization dedicated to the development of such friendly environmental practices, that exists as a global coalition of eye societies providing education and resources to support sustainable practices in ophthalmology.

Here is a sampling of the ASCRS discussions on the topic.

Greening eye care: reducing ophthalmology’s environmental footprint

The presenters, led by first author Sarishka Desai, BA, described the EyeSustain platform and its 5-pronged mission: educate the global ophthalmic community about more sustainable practices, collaborate with industry to reduce our carbon footprint and surgical waste, support research and innovative solutions that reduce ophthalmology’s environmental impact, support advocacy and education about the public health impact of climate change, and collaborate with industry to reduce our carbon footprint and surgical waste.

Desai, of the University of Connecticut School of Medicine in Farmington, and colleagues presented EyeSustain’s approach to reducing the ophthalmic carbon footprint. She was joined in the study by Nitya Devireddy, BS, MPH, of Penn State College of Medicine in Hershey, Pennsylvania; Sofia Miguez, BA, of Yale School of Medicine in New Haven, Connecticut; and Barbara Erny, MD, of the Department of Ophthalmology at Stanford University in California.

The greenhouse gas data associated with health care are startling. Health care is responsible for 4.4% of all global greenhouse gas emissions, 71% of which arise from the manufacturing, use, and disposal of medical supplies. Ophthalmology has the highest procedural volume of any surgical specialty, with 50 million cataract surgeries expected to be performed globally each year by 2050, Desai reported.

In light of the procedural data, the authors highlighted 6 areas that are currently undergoing research and quality improvement initiatives through the EyeSustain system.

 of cataract surgeons and nurses by David Chang and Cassandra Thiel found that 93% of respondents believe that the trash associated with OR procedures is excessive, and that methods to reduce waste should be identified and implemented.

 encouraged regulatory agencies to allow electronic instructions for use be disseminated in lieu of the traditional paper instructions included with each cataract pack.

Ongoing projects spearheaded by EyeSustain members, including medical students and ophthalmology residents, are taking a look at educating surgeons and surgical staff about sustainability and the impact of OR waste, OR water consumption, and evaluation of flash sterilization associated with cataract surgery.

In recognition of the fact that medications in the OR represent an estimated $560 million in waste annually, a multisociety position paper

 recently formulated 3 key recommendations: topical drugs in multidose containers can be used for multiple patients in surgical facilities if proper guidelines are followed; topical drugs in multidose containers can be used until the manufacturer’s labeled date of expiration if proper guidelines are followed; and, when applicable, patients should be able to take their partially used medication home for postoperative use.

The Aravind Eye Care system’s low-carbon model from Madurai, India, uses alternate energy sources, transport, infrastructure, and equipment maintenance.

 Studying global systems of eye care and waste produced can provide a deeper understanding of the impact of hospitals and providers on climate change, as well as ideas on how western eye care systems can proactively reduce carbon emissions.

The EyeSustain platform includes ophthalmology-specific action steps for greening offices and clinics in collaboration with the 

Partnerships can be established with large manufacturers to reduce packaging, make instruments reusable, and streamline the manufacturing and distribution processes.

In addition to the impact of practice waste on the environment, EyeSustain also recommends studying the effects of climate change on the incidence rates of ophthalmologic conditions, including cataracts, allergic disease, and glaucoma, among others.

Desai and her colleagues recommended that institutions take the following steps:

Conduct a waste audit to quantify the carbon footprint of an institution’s OR emissions. This includes using the EyeSustain-Zasti Carbon Footprint Calculator, using the Sustainability Index for Disposables in Cataract Surgery calculator for cataract packs to evaluate the item-by-item potential for carbon dioxide savings, and surveying clinical staff to identify areas of perceived excess waste.

Identify key stakeholders at an institution and an enthusiastic, multidisciplinary team and completing the OR Sustainability Pledge (

), which has been completed by ambulatory surgery centers/hospital outpatient departments from 9 countries thus far.

Implement best practices; multisociety recommendations for sustainability are easily accessible at eyesustain.org and My Green Doctor for outpatient/clinic resources and local legislation using the American Academy of Ophthalmology Topical Medical Waste Reduction Act legislative template.

Using phacoemulsification waste to guide changes in surgical sustainability

Adjustments to improve the sustainability of ophthalmic surgical practice can have a large impact when scaled to case volume, according to author Margaret Tharp, BSc, who described this study at the ASCRS meeting. She and her coauthors Stella Protopapas, BA, MPH, and Minka Gill, BSc, are from the Indiana University School of Medicine in Bloomington, whereas David J. Palmer, MD, ABO, is from the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

In their study, they sought to draw connections between results from a 24-hour waste audit at an outpatient surgical center and current resources available from EyeSustain to improve the sustainability of ophthalmic surgical practice.

The authors documented the extensive waste generated from 1 day of surgeries in an institution that included 13 phacoemulsification procedures, 5 plastic surgeries, 3 urologic surgeries, and 5 otolaryngologic cases. The waste products were sorted as medications (eg, propofol, eye drop containers), textiles (eg, surgical gowns, drapes), metals (eg, metal wiring, disposable instruments), and plastics (eg, hard, soft, wrappings).

When the amounts of the waste products were tallied, the authors found that “ophthalmology produced the greatest amount of waste in a single day relative to other operating specialties, despite producing the least amount of waste per case. Most ophthalmic waste was from textiles, hard plastics, and medications,” the authors reported.

The specific 13 phacoemulsification procedures resulted in 95.4 lb of waste broken down as follows: 18.5 lb of hard plastic, 5.5 lb of soft plastic, 8.3 lb of wrapping, 13.5 lb of medications, 41.2 lb of textiles, 6.7 lb of miscellaneous waste, and no metals. Compared with other operating specialties, ophthalmology produced the least amount of waste per case but the greatest amount of waste in total due to the relatively high case volume.

It has been reported that “discarded/unused pharmaceuticals from US cataract surgeries demonstrated waste of [approximately] $150 per case while generating carbon dioxide–equivalent emissions that approximated 25,000 to 100,000 flights from San Francisco, California, to Boston annually.

Small changes can have dramatic results. Tharp and colleagues suggested that the following would have positive consequences.

Revising the use of tetracaine bottles intraoperatively; for example, reusing the bottles between cases or sending the bottles home with patients

Optimizing packaging of surgical supplies and electronic instructions

Utilizing intravenous sedation to limit anesthesia gas carbon dioxide–equivalent emissions

Focusing on cutting waste also creates an opportunity to explore the practices of global leaders in sustainable eye care, such as the efforts of the Aravind Eye Hospitals, which provide similar surgical success rates at a fraction of the waste produced by US practices.

 A downside may be that such practices require significant reuse of materials, central sterilization, and stakeholder diligence, which can require complex interventions, according to Tharp. 

EyeSustain’s Surgical Facility Sustainability Pledge can serve as a guide for ophthalmologists to improve the sustainability of their practice in an approachable and lasting manner.

Factors contributing to the carbon footprint of cataract surgery

Omar Taboun, MSc, a medical student at Western University’s Schulich School of Medicine & Dentistry in London, Ontario, Canada, working under the direction of Netan Choudhry, MD, FRCSC, also described the negative impact of cataract surgery on the environment at the ASCRS meeting.

He commented, “We know that climate change can affect human health through various means, such as adverse weather events causing injury and exposure to pollutants [exacerbating] underlying health conditions. As health care providers, it is our responsibility to treat patients for their conditions that may ultimately be influenced by environmental factors. Counterintuitively, the health care sector is itself a greenhouse gas emitter,” Taboun said.

Surgery contributes significant emissions to the environment through the necessary materials and tools used during procedures. In addition, the need to maintain sterility increases waste.

The term footprint indicates the sum of all emissions direct and indirect resulting from this procedure, Taboun explained, the resultant value of which is typically reported in carbon dioxide equivalents

And although cataract surgery requires only a few minutes to complete, the procedural volume has increased exponentially over the past 2 decades,

Taboun and colleagues developed a 2-fold goal: they wanted to increase their understanding of the carbon footprint and waste accumulation to identify the primary contributors and pinpoint areas for improvement to enhance the sustainability of cataract surgery.

They conducted a literature search of PubMed, Google Scholar, and Medline to identify studies related to the carbon footprint and the elements of cataract surgery. The results yielded 6 studies, with 2 being the basis for this discussion,

He highlighted 3 main points extracted from the published data: the lowest footprint published was just under 6 kg of carbon dioxide equivalents; the highest published footprint was just over 180 kg of carbon dioxide; and the major factors contributing to the footprint include procurement of pharmaceuticals and materials, building and energy use, such as heating/cooling, lighting, electricity-powered tools, and travel by patients and staff to the location where the procedure is performed.

Taboun directed attention to centers that already have sustainable practices in place, such as the Aravind Eye Hospital, which reports the lowest footprint. These sustainable practices include the use of multiple operating tables in a single room; reusing gloves, gowns, and various medical equipment;

and using highly efficient autoclave settings.

Importantly, when these changes were implemented in the Aravind Eye Hospital,

 the rates of endophthalmitis remained comparable to other centers: 0.02% vs from 0.04% to 0.07% reported.

Taboun offered 3 ways that surgeons can offset the negative effects of cataract surgery on the environment—by focusing on procurement, energy use, and travel emissions.

Reduce emissions associated with procurement by collaborating with manufacturers to reduce packaging as much as possible and encouraging recycling in every OR.

Reduce building and energy use by incorporating renewable energy, such as solar panels, and more strategic lighting protocols and optimizing energy use within surgical centers.

Establish outreach clinics closer to more populous regions, whereby mostly staff members must travel, and patients less so, which will reduce travel emissions, along with performing bilateral procedures.

“Implementing sustainable practices, although challenging, will allow us to continuously provide this procedure and restore vision for millions of people at less of a cost to the environment,” Taboun said.

1. Chang DF, Thiel CL; Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste

. 2020;46(7):933-940.doi:10.1097/j.jcrs.0000000000000267

2. Schehlein EM, Hovasesian J, Shukla AG, Talley Rostov A, Findl O, Change DF. Reducing ophthalmic surgical waste through electronic instructions for use: a multi-society position paper. 

. 2024;50(3):197-200. doi:10.1097/j.jcrs.0000000000001381

3. Cleaning and Sterilization Task Force. Reducing topical drug waste in ophthalmic surgery: multisociety position paper

. 2022;48(9):1073-1077; doi:10.1097/j.jcrs.0000000000000975

4. Goel H, Wemyss TA, Harris T, et al. Improving productivity, costs and environmental impact in International Eye Health Services: using the ‘Eyeficiency’ cataract surgical services auditing tool to assess the value of cataract surgical services. 

. 2021 ;6(1):e000642. doi:10.1136/bmjophth-2020-000642. 2021

5. US EPA O. Greenhouse gas equivalencies calculator. United States Environmental Protection Agency. Updated January 2024. https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator

6. Gadani H, Vyas A. Anesthetic gases and global warming: [otentials, prevention and future of anesthesia. 

. 2011;5(1):5-10. doi:10.4103/0259-1162.84171

7. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. 

. 2017;43(11):1391-1398. doi:10.1016/j.jcrs.2017.08.017

8. Pandey D, Agrawal M, Pandey JS. Carbon footprint: current methods of estimation. 

. 2011 ;178(1-4):135-160. doi:10.1007/s10661-010-1678-y

9. Pandey D, Agrawal M, Pandey JS. (2011). Carbon footprint: current methods of estimation. 

. 2011;178(1-4):135-160. doi:10.1007/s10661-010-1678-y

10 Rachmiel R, Trope GE, Chipman ML, Buys YM. Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists. 

11. Morris DS, Wright T, Somner JEA, Connor A. The carbon footprint of cataract surgery. 

. 2013;27(4):495-501. doi:10.1038/eye.2013.

12. Latta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. 

13. Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. 

. 2009;35(4):629-636. doi:10.1016/j.jcrs.2009.01.002

14, Pershing S, Lum F, Hsu S, et al. Endophthalmitis after cataract surgery in the United States: a report from the Intelligent Research in Sight registry, 2013-2017. 

. 2020;127(2):151-158. doi:10.1016/j.ophtha.2019.08.026

Organization eyes green practices, shifting ophthalmology landscape.

Minimizing the carbon footprint of ophthalmic surgeries

Julie Schallhorn, MD, MS, an ophthalmologist at the San Francisco VA, noticed a common struggle among her patients, especially those with limited hand strength and dexterity: applying eye drops was challenging.

Schallhorn also is an associate professor of ophthalmology at the University of California San Francisco.

Many people can relate to this difficulty, particularly when using preservative-free eye drops in single-dose vials. Squeezing out a tiny drop while maintaining precise positioning over the eye is tricky, and even a slight misalignment can cause the drop to miss, running down the cheek and wasting medication. For individuals with conditions like Parkinson’s, the task is even more daunting. This difficulty often leads to early discontinuation of treatment, which can result in more serious issues down the road.

“It is difficult to see patients who are suffering and are not served by the current options,” explained Shallhorn. “This was the major motivation for me!”

Drawing on her bioengineering background, Schallhorn developed a device to simplify eye drop administration. Her prototype, crafted from a single piece of plastic, features a hammer-shaped handle that releases a precise drop of fluid. A stabilizing bar rests on the patient’s cheekbone, ensuring consistent positioning. Since the cheekbone remains a uniform distance from the eye across adults of all genders and ethnicities, Schallhorn was confident her device would work universally.

For Schallhorn, the next step was finding a path to bring her prototype to market, which she found through the Veterans Engineering Health Innovations Center (VEHICLE) at the Louis Stokes Cleveland VA Medical Center. VEHICLE, part of the Technology Transfer Assistance Program (TTAP), focuses on solutions for Veterans with disabilities. There, Schallhorn collaborated with Stephanie Nogan Bailey, program manager and specialist in clinical research protocols and device development, who has a deep understanding of the daily challenges faced by Veterans with movement disorders.

Together, they designed a refined second prototype featuring an ambidextrous, contoured grip and a wider, more stable area for cheekbone support. They also created a front-loading, secure vial holder and built the device with non-slip material to ensure steady, precise delivery of eye drops.

Meanwhile, the Office of Research and Development's (ORD) Technology Transfer Program (TTP) supported patenting and marketing. TTP developed a plan that identified the device’s potential audience, including the growing number of people with Parkinson's disease and the expanding aging population.

With TTP’s market insights and VEHICLE’s design expertise, Schallhorn filed for a patent. TTP then negotiated a licensing and intellectual property agreement, allowing the device to be licensed to RAIN Eye Drops, an online company offering preservative-free eye drops. The new dispenser will be included with each RAIN Eye Drops subscription, expanding access to this essential tool.

“The ability to connect VA researchers and clinicians with top notch biomedical engineers in TTP’s TTAP helps the VA innovators translate their dreams into real world products that help Veterans and the population at large,” said Dr. John Kaplan, TTP director.

TTP has the vital mission of bringing to market inventions created within the VA that could benefit Veterans and all Americans. Since 2020, TTP’s group of engineers have facilitated the introduction of more than 380 VA inventions into the market. The process begins with an idea by a VA physician, researcher, or staff person. Anyone within VA can develop a concept, and TTP is there to partner with the inventor to help create high-level, functional prototypes; perform design and cost analyses; construct technical drawings; and design history files.

“The overall process of development was quite smooth with the innovation lab, and working with the Tech Transfer office made it quite easy,” said Schallhorn. She also encouraged other VA researchers, clinicians, and staff with invention ideas to reach out to TTP as well. “Pursue it! Patients with conditions that are not met by the current treatments need and deserve innovative solutions.”

Originally created to form a pipeline of invention disclosures and medical ideas, TTAP started in the VA Pittsburgh Health Care System in 2018 through the vision of Dr. Kaplan and Dr. Rory Cooper, Pittsburgh Human Engineering Laboratories director. TTAP became the program it is today in 2021 with the establishment of two additional sites in Cleveland and Minneapolis.

VA ophthalmologist invents device to help with eye drops. Va.gov. Published October 28, 2024. Accessed October 29, 2024. https://www.research.va.gov/currents/1024-VA-ophthalmologist-invents-device-to-help-with-eye-drops.cfm

Dr. Julie Schallhorn, an ophthalmologist, developed a device to aid patients with limited dexterity in administering eye drops. Her invention, featuring a hammer-shaped handle and stabilizing bar, ensures precise drop delivery. Collaborating with the Veterans Engineering Health Innovations Center, she refined the prototype for market readiness. The Technology Transfer Program (TTP) facilitated patenting and licensing, enabling distribution through RAIN Eye Drops. TTP supports VA innovations, having introduced over 380 inventions since 2020, and encourages VA staff to pursue innovative solutions for unmet patient needs.

Julie Schallhorn, MD, MS, also is an associate professor of ophthalmology at the University of California San Francisco, has drawn upon her bioengineering background to develop a device to simplify eye drop administration.

Veterans Administration ophthalmologist invents device to help with eye drops

The Gr8 Eye Movement, a disease awareness campaign from Prevent Blindness and Regeneron continues to shine a light on the needs of caregivers of those at risk for developing retinal conditions this fall.

The campaign, which kicked off last year, is designed to elevate the importance of prioritizing eye health with an emphasis on increasing awareness of wet age-related macular degeneration (wAMD), diabetic macular edema (DME) and diabetic retinopathy (DR) and encourages checking eye health regularly with reminders on the 8th of each month.

November is National Family Caregivers Month, and the Gr8 Eye Movement is expanding its focus to emphasize the crucial role of those caring for aging loved ones at risk for these diseases and offering resources to support them.

Findings from a national survey of at-risk adults and their loved ones* show a significant gap in caregivers' understanding of retinal conditions. According to the data, almost 80% of caregivers mistakenly view vision loss as an inevitable part of aging, and fewer than 30% are aware of both wAMD and diabetic retinal diseases DME and DR.

Jeff Todd, president and CEO of Prevent Blindness, noted the misperception that vision loss is an inevitable part of aging can lead caregivers to overlook signs of serious retinal diseases that may be treatable.

“That's why it's so important to educate the public, and for those at risk for retinal diseases and their caregivers, to prioritize eye health,” Todd said. “By monitoring for eye health changes and being vigilant about getting our eyes and our vision checked regularly, caregivers can help protect their loved ones from preventable vision loss and help to maintain a high quality of life."

Data also show that 75% of surveyed caregivers say it would be challenging to care for someone with significant vision loss, underscoring the burden that retinal diseases can have on both patients and their caregivers.

"Consumer education programs like the Gr8 Eye Movement play an important role in addressing knowledge gaps and ensuring that people are not just informed but truly engaged in prioritizing their eye health," said Kevin Clark, vice president of the Ophthalmology Commercial Business Unit at Regeneron. "During National Family Caregivers Month and beyond, we hope to help empower caregivers with the knowledge they need to spot the early signs of serious retinal diseases and support them as they care for their loved ones' vision.

This survey was conducted by Wakefield Research, which collected findings from 667 adults age 55+ who are at risk for retinal diseases and 333 of their loved ones, ages 18 to 54 years old, who are caregivers of those at risk for retinal diseases, from May through June, 2023.

1. Common Misperceptions Among Caregivers of Aging Adults Emphasizes Lack of Awareness of Retinal Diseases - Prevent Blindness. Prevent Blindness. Published October 28, 2024. Accessed October 29, 2024. https://preventblindness.org/caregiver-survey-gr8-eye-movement

The Gr8 Eye Movement campaign, led by Prevent Blindness and Regeneron, aims to raise awareness about retinal conditions and the importance of eye health, particularly for caregivers of at-risk individuals. The campaign highlights the significant knowledge gap among caregivers, with many mistakenly believing vision loss is an inevitable part of aging. It emphasizes the need for regular eye health checks and education to prevent treatable retinal diseases. The campaign also provides resources to support caregivers, especially during National Family Caregivers Month, to help them manage the challenges of caring for individuals with potential vision loss.

The Gr8 Eye Movement campaign by Prevent Blindness and Regeneron emphasizes the critical role of caregivers in eye health, revealing significant gaps in caregivers' awareness of retinal diseases and aging-related vision loss.

Gr8 Eye Movement data spotlights misconceptions and low awareness of serious retinal diseases among caregivers of older adults

Johannes Kepler, a world-renowned astronomer and mathematician, published 

 This classical literature laid the groundwork for optical instruments such as the telescope and introduced the diopter, a unit of measurement central to our work in cataract and refractive surgery. Today, we strive to achieve 0 diopters (ie, emmetropia) and spectacle independence for our patients, a goal made increasingly attainable through advances in technology, including the femtosecond laser.

The principles of femtosecond lasers were first described in 1986 by Gérard Mourou and Donna Strickland, who were both awarded the Nobel Prize in Physics in 2018 for their pioneering work.

 The femtosecond laser offers the safest and most tissue-sparing way to cut an organ and perform surgery on a human being.

Johannes Kepler's introduction of the diopter in 1611 laid the foundation for advancements in optical instruments, crucial for modern cataract and refractive surgery. The femtosecond laser, first described in 1986, revolutionized ophthalmic surgery by offering precise, tissue-sparing capabilities. Key milestones include the development of LASIK and lenticule extraction techniques, enhancing safety and outcomes. The femtosecond laser's applications extend beyond refractive surgery, improving therapeutic interventions. Future innovations, like laser-induced refractive index change, promise further advancements in corneal refractive surgery, maintaining the femtosecond laser's pivotal role in ophthalmology.

A time line marked by innovation, collaboration, and improving patient outcomes.

Bria George, PharmD

Articles

Latest Updated Articles