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A 38-year-old Hispanic male presented to the Bascom Palmer Eye Institute clinic complaining of poor vision since childhood. The patient stated that his vision had been poor since he was a child and wanted to know if glasses could help his vision. He denied any ocular pain, redness, discharge, flashing lights, floaters, or diplopia.

A 38-year-old male complains of poor vision since childhood

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

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.

The journey of the femtosecond laser in ophthalmology began in 1992. Years before, in 1975, photodisruption of ocular tissue with high pulses in the nanosecond and picosecond range was achieved.

 However, the energy required to create the pulses caused mechanical and thermal adverse effects, such as bubble formation. Over time, incremental improvements in laser technology, including the shortening of pulse duration to femtoseconds, opened new opportunities and overcame the obstacles of high-pulse energy. This early milestone made refractive corneal surgery a reality.

Despite initial challenges with lenticule extraction from the cornea, the creation of a corneal flap marked the second significant early milestone for femtosecond lasers. In 1993, an accidental laser injury to the eye of a graduate student at the University of Michigan revealed the potential of femtosecond lasers for ocular surgery.

 Ron Kurtz, MD, the on-call ophthalmologist at the time, observed that the laser beam burned a precise circular silhouette in the student’s retina. This incident led to the revolutionary development of laser-assisted in situ keratomileusis (LASIK).

Key innovators, like Kurtz; Tibor Juhasz, PhD; and Mark S. Blumenkranz, MD, MMS, played pivotal roles in the collaborative innovation that led to the IntraLase femtosecond laser platform (iFS Advanced Femtosecond Laser; Johnson & Johnson Vision). This invention replaced the mechanical microkeratome with a safer, more precise option for LASIK flap creation.

Europe also contributed significantly to the evolution of femtosecond laser technology. In 1999 in Hungary, Imola Ratkay-Traub, MD, PhD, was the first surgeon in Europe to perform a refractive surgery procedure with a femtosecond laser. She later went on to publish the first clinical results, concluding that “femtosecond lasers can produce precise intrastromal cutting, offering significant safety and other advantages [no razor blades, corneal trauma, partial resections, or sterilization issues] over current techniques.”

 This was a monumental step forward, especially considering Hungary’s pivotal role in overcoming the division of Europe during the Cold War.

The military also recognized the benefits of femtosecond laser surgery. A 2006 US Naval study concluded that military pilots who underwent femtosecond LASIK recovered faster and had better vision than those who underwent conventional LASIK with a mechanical microkeratome,

 leading to wider acceptance of the technology in the military.

Modern femtosecond lasers are now also used for lens-based refractive surgery procedures, such as refractive cataract surgery and refractive lens exchange. The LenSx Laser System (Alcon), developed by the same engineers who introduced femtosecond LASIK, marks the third early milestone of femtosecond lasers. It was the first femtosecond laser system designed for use in cataract surgery.

In August 2008, Zoltan Z. Nagy, MD, became the first surgeon worldwide to perform laser-assisted cataract surgery. The procedure was performed at the University Hospital of Budapest in Hungary. One year later, he published early clinical results showing that the femtosecond laser demonstrated higher precision of the capsulorhexis and reduced phaco power compared with a standard cataract surgery technique.

 Since then, various other platforms have been introduced, including the Catalys (Johnson & Johnson Vision), Femto LDV (Ziemer), Lensar Laser System and Ally Adaptive Cataract Treatment System (LENSAR, Inc), and Victus (Bausch + Lomb), providing reliable and safe options for laser-assisted cataract surgery.

Lenticule extraction is another exciting evolution in the history of femtosecond lasers. First performed by Walter Sekundo, MD, PhD, and Marcus Blum, MD, femtosecond lenticule extraction (FLEx) initially required a flap. The procedure was performed with the VisuMax femtosecond laser (Carl Zeiss Meditec). Sekundo’s group showed the procedure provided similar refractive outcomes to wavefront-optimized LASIK with significantly less induction of higher-order aberrations and better mesopic midterm contrast sensitivity.

Other iterations of the FLEx procedure led to the development of small incision lenticule extraction (SMILE), now termed 

. The procedure has gained popularity because of its precision, minimal pain, corneal stability, and low incidence of dry eye. As of August 2023, more than 8 million SMILE procedures had been performed.

 Today, other femtosecond laser platforms can be used to perform lenticule extraction, including the Atos (SCHWIND eye-tech-solutions GmbH), Elita (Johnson & Johnson Vision), and Femto LDV Z8 (Ziemer).

The femtosecond laser’s applications are not limited to refractive surgery; it also has been used to increase the efficiency and safety of therapeutic interventions, including pockets for intrastromal corneal rings and inlays, and to improve vision in patients with keratoconus with techniques like corneal allograft intracorneal ring segments (CAIRS), which was introduced by Soosan Jacob, MS, FRCS, DNB, in 2018.

 During CAIRS, allogenic rings or segments of various types and lengths are placed intracorneally to provide refractive and topographic effects. Today, the procedure can also be customized to achieve variation in the amount of flattening.

Another development in this area has been customized keratoplasty techniques, such as penetrating keratoplasty, anterior lamellar keratoplasty, deep anterior lamellar keratoplasty, Descemet stripping automated endothelial keratoplasty, and Descemet membrane endothelial keratoplasty. These rely on the femtosecond laser to create complex graft-host junctions by customizing the thickness and shape of the graft and creating special wound configurations. Customized keratoplasty with femtosecond lasers can promote wound healing and accelerate visual rehabilitation.

Even with these advances, femtosecond laser technology faces challenges in widespread adoption for therapeutic corneal procedures due to issues like corneal compression formation.

 The cost-effectiveness of such procedures also limits applications of the femtosecond laser for therapeutic corneal procedures.

Looking ahead to future promises, I have my eyes on the progress being made in laser-induced refractive index change (LIRIC). This approach may likely be a major step forward in corneal refractive surgery. Developed in collaboration with SCHWIND eye-tech-solutions and our clinic, LIRIC is a tissue-sparing procedure that modifies the refractive index of the cornea precisely and without compromising its structural integrity. This is achieved by altering its fibril density without removing or disrupting collagen. The laser, which operates at a wavelength of 405 nm, has potential applications for the treatment of myopia, hyperopia, and mixed astigmatism.15,16 In short, a low pulse energy and a high repetition rate denature the collagen fibers and dehydrate the treated area.

The femtosecond laser’s journey, both in the United States and Europe, has been marked by innovation, collaboration, and significant contributions to improving patient outcomes. As we continue to explore new applications and refine existing techniques, the future of femtosecond laser technology in ophthalmology looks incredibly promising.

. 1611. Accessed July 31, 2024. https://archive.org/details/DioptriceByJohannesKeplerAkaIoannisKepleri

Nobel prize for pioneers in ultrashort pulsed laser technology. Trumpf. October 5, 2018. Accessed July 31, 2024. 

https://www.trumpf.com/it_IT/newsroom/comunicati-stampa-internazionali/comunicato-stampa-pagina-con-i-dettagli/release/nobel-prize-for-pioneers-in-ultrashort-pulsed-laser-technology/

Krasnov MM. Laser-phakopuncture in the treatment of soft cataracts. 

 1975;59(2):96-98. doi:10.1136/bjo.59.2.96

Wright K. Laser-accident-turned-surgery breakthrough wins golden goose. 

. September 14, 2022. Accessed August 24, 2024. 

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.

Byron L. Lam

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