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Botulinum toxin type A effect is usually seen 2 to 3 days following injection, with maximal effect at approximately 2 weeks. Touch-ups are not recommended until 2 weeks have passed.

Facial anatomy key to optimal use of botulinum toxin

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. 

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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

A new study from researchers at the Wilmer Eye Institute, Johns Hopkins Medicine, reveals why some patients with wet age-related macular degeneration (wet AMD) fail to experience vision improvement with current treatments and how an experimental drug could enhance existing wet AMD therapies to preserve vision.

Wet AMD, one of two types of AMD, is a progressive eye condition resulting from an overgrowth of blood vessels in the retina. 

Despite the severe vision loss often associated with wet AMD, fewer than half of the patients treated with monthly anti-VEGF injections experience significant vision improvements. Among those who do benefit, most eventually lose these gains over time. 

Proceedings of the National Academy of Sciences

, the Wilmer-led research team explains how anti-VEGF therapies might contribute to the lack of vision improvement by triggering the overexpression of a second protein, ANGPTL4. Like VEGF, ANGPTL4 can stimulate excessive production of abnormal blood vessels in the retina.

“We previously reported that ANGPTL4 increased in patients who did not respond well to anti-VEGF treatment,”said Akrit Sodhi, MD, PhD, corresponding author and associate professor of ophthalmology and the Branna and Irving Sisenwein Professor of Ophthalmology at Johns Hopkins University School of Medicine and the Wilmer Eye Institute. “In this paper, we observed a paradoxical rise in ANGPTL4 in patients who received anti-VEGF injections—the therapy itself activated this protein’s expression.”

The researchers compared VEGF and ANGPTL4 levels in the eye fluid of 52 wet AMD patients at different stages of anti-VEGF treatment. Before anti-VEGF injections, these patients exhibited high levels of both ANGPTL4 and VEGF proteins. After treatment, VEGF levels predictably declined, but ANGPTL4 levels rose, indicating that ANGPTL4 remained active and increased following anti-VEGF injections. This ANGPTL4 activity may lead to blood vessel overgrowth and prevent vision improvement.

The team then explored a solution for patients with increased ANGPTL4 following anti-VEGF treatment by testing the experimental drug 32-134D in mice with wet AMD. This drug reduces levels of HIF-1, a protein involved in wet AMD and diabetic eye disease due to its role in activating VEGF production. Researchers theorized that the HIF-inhibitor 32-134D might similarly reduce ANGPTL4 after anti-VEGF treatment, as ANGPTL4 production is also regulated by HIF-1.

In mice treated with 32-134D, the team observed decreases in HIF-1, VEGF, ANGPTL4, and blood vessel overgrowth. Mice treated solely with anti-VEGF therapies confirmed the team’s findings in human patients: although VEGF levels dropped, ANGPTL4 levels increased, which inhibited the anti-VEGF therapies’ effectiveness in reducing blood vessel growth and vision loss. Combining 32-134D with anti-VEGF treatments prevented increases in HIF-1, VEGF, and ANGPTL4. This combination therapy was more effective than either drug alone, suggesting promise for enhanced wet AMD treatment.

“This work provides a way to improve anti-VEGF therapy for all patients and may help a subset of wet AMD patients who lose vision over time despite treatment,” Sodhi concluded. “We hope this research will advance our three goals related to wet AMD: maximizing the efficacy of current therapies, identifying new treatments, and preventing wet AMD altogether.”

Additional study authors include Deepti Sharma, Evan Lau, Yu Qin, Murilo Rodrigues, Chuanyu Guo, Emma McIntyre, Shaima Salman, Yousang Hwang, and Gregg L. Semenza of Johns Hopkins University School of Medicine; Aumreetam Dinabandhu and Silvia Montaner of the University of Maryland; and Ala Moshiri of the University of California, Davis. Dinabandhu and Qin are also affiliated with Johns Hopkins University School of Medicine and the Eye Hospital of China Medical University, respectively.

This research was supported by National Institutes of Health grants R01EY029750, R01EY032104, and EY001765 (the Wilmer Core Grant for Vision Research, Microscopy, and Imaging Core Module); the TEDCO Maryland Innovation Initiative; Research to Prevent Blindness, Inc.; the Sybil B. Harrington Stein Innovation Award; an unrestricted grant to the Wilmer Eye Institute, Johns Hopkins School of Medicine; the Armstrong Family Foundation; the C. Michael Armstrong Professorship; and the Branna and Irving Sisenwein Professorship in Ophthalmology. The funding organizations had no role in designing or conducting the study.

Akrit Sodhi and Gregg L. Semenza are co-founders of and hold equity in HIF Therapeutics, Inc. Shaima Salman, Yousang Hwang, Akrit Sodhi, and Gregg L. Semenza are inventors on a provisional patent application, PCT/US2022/039883. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies.

1. D. Sharma, E. Lau, Y. Qin, K. Jee, M. Rodrigues, C. Guo, A.Dinabandhu, E. McIntyre, S. Salman, Y. Hwang, A. Moshiri, G.L.Semenza, S. Montaner, A. Sodhi, VEGF inhibition increases expression of HIF-regulated angiogenic genes by the RPE limiting the response of wet AMD eyes to aflibercept, 

 121 (46) e2322759121. Published November 4, 2024. Accessed November 5, 2024. 

Researchers at Johns Hopkins Medicine have identified why some wet AMD patients do not benefit from anti-VEGF treatments and proposed a potential solution. Anti-VEGF therapies may inadvertently increase ANGPTL4 protein levels, which can stimulate abnormal blood vessel growth, counteracting treatment benefits. An experimental drug, 32-134D, was tested in mice and shown to reduce HIF-1, VEGF, and ANGPTL4 levels, enhancing treatment efficacy. This combination therapy could improve outcomes for patients who lose vision despite current treatments, offering a promising advancement in wet AMD management.

A Johns Hopkins study reveals that anti-VEGF treatments for wet AMD may unintentionally elevate ANGPTL4, a protein that promotes blood vessel growth. Combining anti-VEGF with an experimental drug targeting HIF-1 could enhance vision outcomes and prevent vision loss.

Researchers offer insights into wet AMD: Study reveals potential to enhance anti-VEGF therapy with experimental drug to preserve vision

At the 2024 American Academy of Ophthalmology (AAO) meeting, held October 18 to 21 in Chicago, Illinois, ophthalmologists and researchers from around the world convened to share groundbreaking insights on the latest advancements in eye care. From novel approaches to treating age-related macular degeneration (AMD) to advancements in cataract surgery and ocular gene therapies, this year’s presentations covered a wide range of transformative developments.

covered myriad innovative studies, new treatment strategies, and emerging technologies aimed at improving patient outcomes across various subspecialties in ophthalmology.

Here are the top 10 highlights covering the latest ophthalmic advancements from this year’s AAO.

1. Promising Treatment for Corneal Neovascularization

Mitomycin intravascular chemoembolization is being used to treat corneal neovascularization. In the procedure, mitomycin seed is injected directly into some of the feeder vessels. This treatment was highlighted as a new and promising procedure in treating a common and serious eye condition, making it a significant breakthrough. However, proper patient selection is key, with the MICE procedure most effective with specific vessel types and conditions that are amenable to canulization.

AAO 2024: New study shows promise for mice procedure in treating corneal neovascularization

2. Advances in Epigenetic Reprogramming for Vision Restoration

The concept of restoring visual function through epigenetic reprogramming is cutting-edge and presents a novel avenue in treating age-related vision loss. ER-100, a novel gene therapy utilizing partial epigenetic reprogramming with the transcription factors Oct-4, Sox-2, and Klf-4 (OSK), was delivered via a single intravitreal injection in combination with daily systemic doxycycline to non-human primates (NHPs) with an induced NAION-like injury. Immunohistochemistry confirmed the expression of these transcription factors (Oct-4, Sox-2, and Klf-4) in distinct perifoveal cells in the ER-100-treated group compared to the vehicle-treated controls.

Life Biosciences reports advances in nonhuman primate studies on partial epigenetic reprogramming for restoring visual function

This IOL system could revolutionize the treatment of presbyopia and cataracts, which are prevalent in the aging population. The two-year clinical outcomes are significant. Data show how the next generation of accommodating lenses are performing, including safety and efficacy profiles. Researchers have found the lenses are maintaining refractive stability over 24 months. The system features a modular, exchangeable anterior optic and a fluid-filled, shape changing base that provides accommodation.

AAO 2024: Two-year clinical feasibility trial outcomes for a dual-optic IOL system for the treatment of presbyopia and cataract

Age-related macular degeneration (AMD) is a leading cause of vision loss, and this drug is one of the first to show promise in protecting vision, making it a highly important development. In a study, patients receiving monthly treatment with the investigational drug ANX007 reduced their risk of vision loss by 72 percent. The data also show that significant areas of the retina essential for maintaining good vision were preserved.

AAO 2024: New drug shows promise as first to protect vision in patients with dry AMD

5. Early Cataract Extraction for Angle Closure Glaucoma

Cataracts are a common issue in glaucoma patients, and the ability to prevent or reduce complications through early extraction is a significant clinical advancement. Early cataract extraction may offer better outcomes for angle closure glaucoma compared to laser iridotomy and medications, as shown in the EAGLE trial. Moreover, cataract surgery also alleviates pupillary blocks, opens angles, and relaxes the ciliary body, leading to long-term benefits and reduced medication dependency. 

AAO 2024: Early cataract extraction for angle closure glaucoma

The 2024 American Academy of Ophthalmology meeting showcased significant advancements in eye care, including novel treatments for corneal neovascularization and age-related macular degeneration (AMD), and innovations in cataract surgery and ocular gene therapies. Highlights included promising results from mitomycin intravascular chemoembolization for corneal neovascularization, epigenetic reprogramming for vision restoration, and a dual-optic IOL system for presbyopia. Additionally, early cataract extraction for angle closure glaucoma, new gene therapy for Stargardt disease, and teleretinal screening for diabetic eye disease were discussed, emphasizing the transformative potential of these developments.

This year’s conference in Chicago showcased a diverse array of practice-changing data across multiple ophthalmic specialties, including advances in cataract surgery, glaucoma management, and retinal disease treatments.

John R. Burroughs, MD

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