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Hyaluronic acid fillers are used for undereye volume correction, detailing aging effects on facial anatomy, common complications, and optimal injection techniques. Imaging tools such as MRI can prove to be beneficial for patient assessment.

Blog: MRI findings of undereye filler and filler migration

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

VEGF-A therapy has revolutionized treatment and visual outcomes for patients with neovascular 

. Ranibizumab, the first anti–VEGF-A agent to be FDA approved, was introduced more than 18 years ago. Despite the introduction of additional nAMD therapies over the years, visual outcomes obtained have been comparable to outcomes from the ANCHOR (NCT00061594) and MARINA (NCT00056836) trials showing between 8 and 11 letters of visual gain at 2 years.

Based on real-world evidence, patients do not always see either the gain in meaningful and functional vision or the durability elucidated in findings from randomized clinical trials.

 Drug developers are looking to improve upon these outcomes.

Large, pivotal randomized clinical trials have typically evaluated treatments with fixed-interval scheduled injections. Findings from studies of as-needed dosing (after loading doses) show markedly inferior treatment outcomes after 2 years compared with fixed-interval dosing, treat-and-extend regimens, and the treat-
extend-stop protocol.

 For real-world patients, visual acuity (VA) is largely dependent on the number of treatments received annually and treatment regimen. Findings from long-term studies demonstrate the variability.

In findings from the CATT trial (NCT00593450), either ranibizumab or bevacizumab given on a monthly or as-needed basis was effective at 2 years, but mean VA gains were not maintained at 5 years in the extension study findings, with many patients managed using as-needed dosing.

 Long-term outcomes of patients in the ANCHOR and MARINA trials and the HORIZON extension study (NCT00379795) extension showed an overall mean decline in VA falling below baseline best-corrected VA (BCVA).

On the other hand, patients treated with more frequent fixed-dose aﬂibercept in the VEGF trap-eye extension were able to maintain visual improvement at 96 weeks.

 My colleagues and I studied patients with nAMD who had consistent anti-VEGF therapy, received 50 or more injections, and were managed with a treat-extend-stop protocol.

At an average of 8.5 years, these patients were able to maintain their visual improvement of 8.5 letters when compared with their initial vision.

 In order to achieve these results, the treatment burden was high, typically requiring intravitreal injections every 6 to 8 weeks. Newer anti-VEGF agents have studied increased treatment intervals between injections.

When evaluating a therapy’s durability, it is important to consider that the criteria commonly used in clinical trials to give supplemental injections are not quite how we would treat patients in our real-world clinics. Trial rescue criteria typically require a fluid increase of 50 or 75 μm and/or a drop in vision of 5 to 10 letters before patients can receive more frequent injections. In real-world practice, I may tolerate an increase of only 20 to 30 μm of subretinal fluid before I would either shorten the time interval between injections or switch anti-VEGF agents. In my experience, some patients can go 4 months between injections on high-dose aflibercept (Eylea; Genentech) and faricimab-svoa (Vabysmo; Genentech), but that is not true for a majority of real-world patients.

Regardless of the treatment durability, patients still gain 7 to 10 letters or approximately 1.5 to 2 lines of vision with anti–VEGF-A inhibition. Of course, this is exciting coming from where we started. Nevertheless, we still see a ceiling effect with our standard-of-care agents. I am less concerned with the treatment burden if we are showing patients that they’re obtaining improved visual outcomes. I’m always on the side of getting the best possible vision for my patients.

Innovations in the nAMD landscape currently under investigation in phase 2 and 3 clinical trials include gene therapy, tyrosine kinase inhibitors, and dual-target drugs. Neovascular macular degeneration is multifactorial, which requires future agents to target multiple pathways. We know, for example, that with faricimab-svoa, its dual inhibition of VEGF-A and angiopoietin-2 is likely playing a role in its increased durability. However, the visual outcomes were still found to be noninferior to aflibercept in findings from a large randomized clinical trial.

Although the role of VEGF-A is the most well studied, the entire VEGF family of ligand proteins and their receptors play a role in maintaining tissue homeostasis and regulating disease. In addition to VEGF-A, these consist of VEGF-B, VEGF-C, VEGF-D, placental growth factor, and VEGF receptors VEGFR-1, VEGFR-2,
and VEGFR-3, which are expressed on vascular endothelium. Specifically in retinal vascular diseases, their pathogenic activity is seen in angiogenesis and increased vascular permeability.

VEGF-C and VEGF-D have been found in the human vitreous and are expressed in the retinal pigment epithelium of patients with nAMD; VEGF-C is elevated in the blood and retinal tissue of patients with nAMD.

 It has further been shown that inhibiting VEGF-A upregulates VEGF-C and VEGF-D, which may play a role in the limitation of anti–VEGF-A monotherapies.

Sozinibercept (OPT-302; Opthea) is a novel, first-in-class recombinant fusion protein trap that binds to and neutralizes VEGF-C and VEGF-D. Highly specific for VEGF-C and VEGF-D, it does not bind to VEGF-A and is being studied in combination with standard-of-care agents. This agent is the only late-stage therapy in development looking to improve VA. In the phase 2b investigation of 366 patients, sozinibercept plus ranibizumab demonstrated superior visual outcomes compared with monthly ranibizumab alone.

Patients assigned to combination treatment had a mean change in BCVA from baseline to week 24 of 14.2 letters, representing a statistically significant additional gain of 3.4 letters (

 = .0107) compared with the ranibizumab monotherapy control group. Even greater VA gains of 5.7 letters were achieved compared with the control group in prespecified analyses of patients with minimally classic/occult lesions, which make up approximately 85% of clinical nAMD cases encountered.

Two concurrent pivotal phase 3 studies, ShORe (NCT04757610; 2 mg sozinibercept plus 0.5 mg ranibizumab) and COAST (NCT04757636; 2 mg sozinibercept plus 2 mg aflibercept), are fully enrolled and underway.

 Opthea has noted that the company plans to submit registrational regulatory filings following a 12-month primary efficacy analysis.

If we can enhance patients’ VA further, that is huge for all sorts of functional abilities. Findings from studies have shown that if you can improve a patient’s VA of 20/100 to 20/80, they are able to function better in their home. A patient with VA of 20/50 whose vision improves to 20/40 can now drive. If a therapy requires a few more injections over the treatment course to gain patients more vision with the associated quality of life benefits, in my mind, that is more important than longer periods between treatments.

There is more to the pathophysiology of nAMD than VEGF-A. Despite the huge strides made in our use of anti–VEGF-A agents, the treatment burden is high and visual gains can be improved upon. With the next generation of nAMD treatments pioneered by sozinibercept among others, we seek to improve visual outcomes beyond what is seen with standard of care.

Adrean is in practice at Retina Consultants of Orange County in Fullerton, California.

Mehta H, Tufail A, Daien V, et al. Real-world outcomes in patients with neovascular age-related macular degeneration treated with intravitreal vascular endothelial growth factor inhibitors. 

. 2018;65:127-146. doi:10.1016/j.preteyeres.2017.12.002

Ciulla TA, Huang F, Westby K, Williams DF, Zaveri S, Patel SC. Real-world outcomes of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration in the United States. 

. 2018;2(7):645-653. doi:10.1016/j.oret.2018.01.006

Kiss S, Campbell J, Almony A, et al. Management and outcomes for neovascular age-related macular degeneration: analysis of United States electronic health records. 

. 2020;127(9):1179-1188. doi:10.1016/j.ophtha.2020.02.027

Wykoff CC, Garmo V, Tabano D, et al. Impact of anti-VEGF treatment and patient characteristics on vision outcomes in neovascular age-related macular degeneration: up to 6-year analysis of the AAO IRIS Registry. 

. 2023;4(2):100421. doi:10.1016/j.xops.2023.100421

VEGF-A therapy has significantly improved treatment outcomes for neovascular age-related macular degeneration (nAMD), yet real-world results often fall short of clinical trial findings. Fixed-interval dosing generally yields better visual acuity than as-needed regimens. Newer therapies, like sozinibercept, aim to enhance visual outcomes by targeting additional pathways beyond VEGF-A. Sozinibercept, a VEGF-C/D inhibitor, has shown promising results in combination with standard treatments, offering superior visual gains. Ongoing phase 3 trials are evaluating its efficacy. Despite advancements, treatment burden remains high, necessitating further innovation in nAMD management.

Julie Anush Kazaryan, BS

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